MEDICARE: CASA ROSE VILLA 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	366405874	CA

General Provider Information

NPI Number	:	1750511028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASA ROSE VILLA INC.

Provider Business Mailing Address
First Line	:	9204 APRICOT AVE
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-3404
Country	:	US
Telephone Number	:	909-989-4887
Fax Number	:

Provider Business Practice Location Address
First Line	:	9204 APRICOT AVE
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-3404
Country	:	US
Telephone Number	:	909-989-4887
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LYNN MCGUIRE
Credential	:
Telephone Number	:	909-730-0391

Provider Enumeration Date	:	07/21/2009
Last Update Date	:	07/21/2009

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