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General NPI Number Information
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NPI Number | 1316499536
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Entity Type | Organization
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Legal Business Name | EVERETT FOREST,LLC
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Dates
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Enumeration Date | 11/04/2016
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Last Update Date | 01/27/2017
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Provider Practice Location Address
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Address Line | 11350 POPLAR ST
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City | LOMA LINDA
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State | CA
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Zip | 92354-3519
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Country | US
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Telephone | 909-799-3170
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Fax | 909-799-1381
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Provider Business Mailing Address
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Address Line | 11350 POPLAR ST
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City | LOMA LINDA
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State | CA
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Zip | 92354-3519
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Country | US
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Telephone | 909-799-3170
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Fax | 909-799-1381
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Authorized Official
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Title or Position | LICENSEE AND ADMINISTRATOR
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Name | ANGELO SWANSON GALASINAO
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Credential | ADMINISTRATOR
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Telephone | 909-799-3170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 366410695
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License Number State | CA
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