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General NPI Number Information
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NPI Number | 1538609987
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Entity Type | Organization
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Legal Business Name | PREMIERCARE 1 CONGREGATE LIVING, INC.
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Dates
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Enumeration Date | 03/05/2017
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Last Update Date | 02/22/2021
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Provider Practice Location Address
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Address Line | 3141 EUCLID AVE
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City | LYNWOOD
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State | CA
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Zip | 90262-4971
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Country | US
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Telephone | 186-423-6688
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Fax |
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Provider Business Mailing Address
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Address Line | 5924 E LOS ANGELES AVE STE M
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City | SIMI VALLEY
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State | CA
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Zip | 93063-5526
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Country | US
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Telephone | 818-642-3668
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Fax | 805-582-0915
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | MARILYN VAN NGUYEN
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Credential | RN
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Telephone | 818-642-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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