MEDICARE: ANGEL 1004 RESIDENTIAL HOME

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

General Provider Information

NPI Number	:	1609719764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL 1004 RESIDENTIAL HOME

Provider Business Mailing Address
First Line	:	7142 VERDUGO PL
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-1452
Country	:	US
Telephone Number	:	909-855-3105
Fax Number	:

Provider Business Practice Location Address
First Line	:	7142 VERDUGO PL
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-1452
Country	:	US
Telephone Number	:	909-855-3105
Fax Number	:

Authorized Official
Title or Position	:	LICENSEE
Name	:	HAEJIN KIM
Credential	:
Telephone Number	:	909-855-3105

Provider Enumeration Date	:	04/13/2026
Last Update Date	:	04/13/2026

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