Healthcare Provider Details

I. General information

NPI: 1356707533
Provider Name (Legal Business Name): AVANTGARDE SENIOR LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 LINDLEY AVE
TARZANA CA
91356-2557
US

IV. Provider business mailing address

5645 LINDLEY AVE
TARZANA CA
91356-2557
US

V. Phone/Fax

Practice location:
  • Phone: 818-881-0055
  • Fax: 818-881-0619
Mailing address:
  • Phone: 818-881-0055
  • Fax: 818-881-0619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number197608081
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number197608080
License Number StateCA

VIII. Authorized Official

Name: JASON MICHAEL ADELMAN
Title or Position: PRESIDENT
Credential:
Phone: 818-692-5284