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General NPI Number Information
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NPI Number | 1740668490
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Entity Type | Organization
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Legal Business Name | SONG OF PHOENIX
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Dates
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Enumeration Date | 05/14/2015
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Last Update Date | 05/14/2015
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Provider Practice Location Address
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Address Line | 22302 HALLDALE AVE
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City | TORRANCE
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State | CA
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Zip | 90501-4232
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Country | US
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Telephone | 310-320-5350
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Fax | 310-320-5350
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Provider Business Mailing Address
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Address Line | 22302 HALLDALE AVE
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City | TORRANCE
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State | CA
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Zip | 90501-4232
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Country | US
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Telephone | 310-320-5350
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Fax | 310-320-5350
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ROGER BRITO
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Credential |
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Telephone | 424-376-8931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 197607370
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License Number State | CA
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