=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033353701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHRIDGE GOLDEN NEST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2009
-----------------------------------------------------
Last Update Date | 04/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9314 TAMPA AVE
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-472-2366
-----------------------------------------------------
Fax | 818-886-1230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9314 TAMPA AVE
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-472-2366
-----------------------------------------------------
Fax | 818-886-1230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. GALIT PELED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-472-2366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 197605610
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 197604051
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------