MEDICARE: MODEL RESIDENTIAL 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	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1427322304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODEL RESIDENTIAL HOME, INC.

Provider Business Mailing Address
First Line	:	1963 LA FREMONTIA ST
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-4226
Country	:	US
Telephone Number	:	323-254-3621
Fax Number	:	323-254-3655

Provider Business Practice Location Address
First Line	:	1621 LINDA ROSA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-2225
Country	:	US
Telephone Number	:	323-254-3621
Fax Number	:	323-254-3655

Authorized Official
Title or Position	:	OWNER/LICENSEE
Name	:	EVELYN MORENO
Credential	:
Telephone Number	:	323-254-3621

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	02/24/2012

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