1972024420 NPI number — BELLA VITA CONGREGATE LIVING, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972024420 NPI number — BELLA VITA CONGREGATE LIVING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLA VITA CONGREGATE LIVING, LLC
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:
1972024420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17130 VAN BUREN BLVD # 134
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92504-5905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-800-8435
Provider Business Mailing Address Fax Number:
951-429-7162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16092 CONSTABLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92504-5664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-800-8435
Provider Business Practice Location Address Fax Number:
951-429-7162
Provider Enumeration Date:
07/05/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HARRELL
Authorized Official First Name:
SONYA
Authorized Official Middle Name:
LISETTE
Authorized Official Title or Position:
NURSE ADMINISTRATOR/OWNER
Authorized Official Telephone Number:
951-640-8170

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  550003868 , 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)





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