=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407542707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALOS VERDES CARE COTTAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2023
-----------------------------------------------------
Last Update Date | 04/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1808 PENINSULA VERDE DR
-----------------------------------------------------
City | RANCHO PALOS VERDES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90275-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-356-7130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1808 PENINSULA VERDE DR
-----------------------------------------------------
City | RANCHO PALOS VERDES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90275-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-356-7130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MA. SALVACION FABIANA MEDINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-356-7130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------