=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881025898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISTA COVE AT SAN GABRIEL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2013
-----------------------------------------------------
Last Update Date | 12/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 W SANTA ANITA ST
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-289-8889
-----------------------------------------------------
Fax | 626-289-1461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 SAN JOAQUIN PLZ STE 350
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-5969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-205-4052
-----------------------------------------------------
Fax | 949-205-4053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | MR. BONAPARTE H LIU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-205-4060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 197606796
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------