=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740672757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELNA C VILLAFLOR ADMINISTRATOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2015
-----------------------------------------------------
Last Update Date | 02/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1809 LEANING PINE DR
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-860-2538
-----------------------------------------------------
Fax | 909-860-5628
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1142 S DIAMOND BAR BLVD # 336
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-860-2538
-----------------------------------------------------
Fax | 909-860-5628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 197801279
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 197801933
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 336407270
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 197606472
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------