=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497517973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEISURE GROVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 413 E CYPRESS ST
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91205-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-244-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4221 WILSHIRE BLVD STE 392
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-475-1800
-----------------------------------------------------
Fax | 323-475-1826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | STEVEN ATLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-475-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------