MEDICARE: L. MARILLAC GROUP 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	315P00000X	Intellectual Disabilities Intermediate Care Facility		CA

General Provider Information

NPI Number	:	1679781884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L. MARILLAC GROUP HOME

Provider Business Mailing Address
First Line	:	23711 PROSPECT VALLEY DR
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-1637
Country	:	US
Telephone Number	:	909-821-3698
Fax Number	:	909-860-7614

Provider Business Practice Location Address
First Line	:	23711 PROSPECT VALLEY DR
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-1637
Country	:	US
Telephone Number	:	909-821-3698
Fax Number	:	909-860-7614

Authorized Official
Title or Position	:	LICENSEE
Name	:	GRACE VILLEGAS
Credential	:
Telephone Number	:	909-821-3698

Provider Enumeration Date	:	05/19/2007
Last Update Date	:	08/22/2020

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