MEDICARE: HEAVENLY MANOR ELDERLY CARE LLC

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	197608684	CA

General Provider Information

NPI Number	:	1770953499
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY MANOR ELDERLY CARE LLC

Provider Business Mailing Address
First Line	:	7708 ETHEL AVE.
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-0000
Country	:	US
Telephone Number	:	818-434-3089
Fax Number	:	818-765-7791

Provider Business Practice Location Address
First Line	:	7708 ETHEL AVE.
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-0000
Country	:	US
Telephone Number	:	818-434-3089
Fax Number	:	818-765-7791

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARIAM KRATIAN
Credential	:
Telephone Number	:	818-434-3089

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	10/07/2015

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