MEDICARE: PACIFICA ROYALE ASSISTED LIVING COMMUNITY, 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	306001848	CA

General Provider Information

NPI Number	:	1558779694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFICA ROYALE ASSISTED LIVING COMMUNITY, INC.

Provider Business Mailing Address
First Line	:	15022 PACIFIC ST
Second Line	:
City	:	MIDWAY CITY
State	:	CA
Zip	:	92655-1452
Country	:	US
Telephone Number	:	714-892-4446
Fax Number	:

Provider Business Practice Location Address
First Line	:	15022 PACIFIC ST
Second Line	:
City	:	MIDWAY CITY
State	:	CA
Zip	:	92655-1452
Country	:	US
Telephone Number	:	714-892-4446
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. EDWARD MASLOBODSKY
Credential	:
Telephone Number	:	714-588-3047

Provider Enumeration Date	:	07/31/2014
Last Update Date	:	07/31/2014

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