MEDICARE: QUEEN COMFORT CARE CENTER

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	302R00000X	Health Maintenance Organization	197608550	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598149387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEEN COMFORT CARE CENTER

Provider Business Mailing Address
First Line	:	6534 MCLENNAN AVE
Second Line	:
City	:	LAKE BALBOA
State	:	CA
Zip	:	91406-5543
Country	:	US
Telephone Number	:	818-616-1761
Fax Number	:

Provider Business Practice Location Address
First Line	:	6534 MCLENNAN AVE
Second Line	:
City	:	LAKE BALBOA
State	:	CA
Zip	:	91406-5543
Country	:	US
Telephone Number	:	818-616-1761
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. NINO GELASHVILL
Credential	:
Telephone Number	:	818-370-2339

Provider Enumeration Date	:	07/12/2015
Last Update Date	:	07/12/2015

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Directions to “QUEEN COMFORT CARE CENTER ” Practice Location

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