MEDICARE: VILLA DE MARTIN JUDE HOMES ATLANTA HOUSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility		CA

General Provider Information

NPI Number	:	1316377229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLA DE MARTIN JUDE HOMES ATLANTA HOUSE

Provider Business Mailing Address
First Line	:	2204 S ATLANTA ST
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92802-3905
Country	:	US
Telephone Number	:	714-539-0696
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 S ATLANTA ST
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92802-3905
Country	:	US
Telephone Number	:	714-539-0696
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MR. RAMON LOPEZ
Credential	:
Telephone Number	:	714-746-4294

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	11/14/2013

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