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	320700000X	Physical Disabilities Residential Treatment Facility	550003098	CA

General Provider Information

NPI Number	:	1619336740
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	:
Fax Number	:

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	:	805-557-0010
Fax Number	:	805-557-0020

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	GALINA BLANK
Credential	:
Telephone Number	:	323-428-4258

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	02/17/2016

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