MEDICARE: AXALAN CUNANAN LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1336964881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXALAN CUNANAN LLC

Provider Business Mailing Address
First Line	:	5203 JOSIE AVE
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90713-2110
Country	:	US
Telephone Number	:	720-530-9218
Fax Number	:

Provider Business Practice Location Address
First Line	:	5203 JOSIE AVE
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90713-2110
Country	:	US
Telephone Number	:	720-530-9218
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE AXALAN
Credential	:
Telephone Number	:	720-530-9218

Provider Enumeration Date	:	11/20/2024
Last Update Date	:	11/21/2024

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