=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083004683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLA CELERINA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19208 SHERYL AVE
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-6622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-860-0189
-----------------------------------------------------
Fax | 562-865-0719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19208 SHERYL AVE
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-6622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-860-0189
-----------------------------------------------------
Fax | 562-865-0719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MERLYN M EVANGELISTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-822-3662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 198205167
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------