MEDICARE: 535 W BROADWAY INC

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	191221839	CA

General Provider Information

NPI Number	:	1376734087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	535 W BROADWAY INC

Provider Business Mailing Address
First Line	:	535 W BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1131
Country	:	US
Telephone Number	:	818-246-4951
Fax Number	:	818-243-0437

Provider Business Practice Location Address
First Line	:	535 W BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-1131
Country	:	US
Telephone Number	:	818-246-4951
Fax Number	:	818-243-0437

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PAUL SOLOMON
Credential	:
Telephone Number	:	818-246-4951

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	07/03/2008

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