Healthcare Provider Details

I. General information

NPI: 1740772631
Provider Name (Legal Business Name): SINALOA CONGREGATE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 SINALOA RD
SIMI VALLEY CA
93065-3031
US

IV. Provider business mailing address

1432 SINALOA RD
SIMI VALLEY CA
93065-3031
US

V. Phone/Fax

Practice location:
  • Phone: 805-842-1990
  • Fax:
Mailing address:
  • Phone: 805-842-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: KELLY FABROS
Title or Position: MANAGER
Credential:
Phone: 310-991-3733