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General NPI Number Information
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NPI Number | 1023885910
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Entity Type | Organization
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Legal Business Name | FOOTHILL SERENITY LIVING LLC
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Dates
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Enumeration Date | 12/11/2023
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Last Update Date | 12/11/2023
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Provider Practice Location Address
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Address Line | 8024 REDWOOD AVE
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City | FONTANA
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State | CA
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Zip | 92336-1640
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Country | US
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Telephone | 909-371-3966
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Fax |
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Provider Business Mailing Address
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Address Line | 235 CHESTNUT AVE
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City | LOS ANGELES
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State | CA
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Zip | 90042-3735
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Country | US
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Telephone | 213-618-0938
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Fax | 213-618-0938
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Authorized Official
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Title or Position | SOLE LLC MEMBER
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Name | MARYDES A GUEVARRA
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Credential |
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Telephone | 213-618-0938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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