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General NPI Number Information
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NPI Number | 1356619019
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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 | 12/09/2011
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 5129 LOLETA AVE
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City | LOS ANGELES
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State | CA
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Zip | 90041-1501
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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 | 1963 LA FREMONTIA ST
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-4226
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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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Authorized Official
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Title or Position | OWNER/LICENSEE
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Name | EVELYN MORENO
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Credential | R.N.
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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 |
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License Number State |
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