1336138999 NPI number — HOLIDAY MANOR CARE CENTER

Table of content: (NPI 1336138999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336138999 NPI number — HOLIDAY MANOR CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLIDAY MANOR CARE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336138999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20554 ROSCOE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANOGA PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91306-1746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-341-9800
Provider Business Mailing Address Fax Number:
818-341-1925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20554 ROSCOE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANOGA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91306-1746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-341-9800
Provider Business Practice Location Address Fax Number:
818-341-1925
Provider Enumeration Date:
10/17/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SOSING
Authorized Official First Name:
VICTORIO
Authorized Official Middle Name:
OCBENA
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
818-341-9800

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZT18160G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".