Healthcare Provider Details

I. General information

NPI: 1134504459
Provider Name (Legal Business Name): SUNRISE CONGREGATE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14538 LEADWELL ST
VAN NUYS CA
91405-1905
US

IV. Provider business mailing address

14538 LEADWELL ST
VAN NUYS CA
91405-1905
US

V. Phone/Fax

Practice location:
  • Phone: 818-287-8584
  • Fax: 818-436-0340
Mailing address:
  • Phone: 818-287-8584
  • Fax: 818-436-0340

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: EDUARD SHALJYAN
Title or Position: CEO
Credential:
Phone: 818-287-8584