MEDICARE: AVENIDA LIVING HOME, 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	313M00000X	Nursing Facility/Intermediate Care Facility

General Provider Information

NPI Number	:	1417347121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENIDA LIVING HOME, INC.

Provider Business Mailing Address
First Line	:	2465 AVENIDA DE LAS PLANTAS
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-6619
Country	:	US
Telephone Number	:	310-435-7575
Fax Number	:	888-369-2111

Provider Business Practice Location Address
First Line	:	2465 AVENIDA DE LAS PLANTAS
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-6619
Country	:	US
Telephone Number	:	310-435-7575
Fax Number	:	888-369-2111

Authorized Official
Title or Position	:	CEO
Name	:	MR. LIOR MATIAN
Credential	:
Telephone Number	:	310-465-7575

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	02/02/2015

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