=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174861108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEISURE CARE HOME CARE AGENCY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2013
-----------------------------------------------------
Last Update Date | 01/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30131 TOWN CENTER DR SUITE 205
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-363-7401
-----------------------------------------------------
Fax | 949-363-7419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30131 TOWN CENTER DR SUITE 205
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-363-7401
-----------------------------------------------------
Fax | 949-363-7419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TREVOR L BLACKANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-363-7401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | C-2616981
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------