=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396223111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED HEART ASSISTED LIVING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2018
-----------------------------------------------------
Last Update Date | 08/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23911 VIA LA CORUNA
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-3526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-206-1507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 TRUMPET VINE ST
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-0737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-257-8344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL/TREASURER
-----------------------------------------------------
Name | BRUCE SMERKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-257-8449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------