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General NPI Number Information
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NPI Number | 1073721288
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Entity Type | Organization
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Legal Business Name | MODEL RESIDENTIAL HOME, INC
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Dates
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Enumeration Date | 05/19/2007
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 2227 LAVERNA AVE
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City | LOS ANGELES
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State | CA
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Zip | 90041-2624
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Country | US
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Telephone | 323-254-3621
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Fax | 323-254-3655
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Provider Business Mailing Address
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Address Line | 2227 LAVERNA AVE
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City | LOS ANGELES
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State | CA
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Zip | 90041-2624
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Country | US
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Telephone | 323-254-3621
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Fax |
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Authorized Official
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Title or Position | LICENSEE
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Name | EVELYN MORENO
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Credential |
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Telephone | 323-254-3621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 960001042
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License Number State | CA
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