Organization
JO MI ICF DDN FACILITIES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROGER V. CUEVAS (BUSINESS MANAGER)
(818) 841-1044
Entity
Organization
Contact information
Practice address
2128 SHIRLEE ST, WEST COVINA, CA 91792-2431
(626) 854-0670
Mailing address
1849 AYERS WAY, BURBANK, CA 91501-1106
(818) 841-1044
(818) 841-4403
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LTC80031F
LONG TERM CARE
CA
01
—
LTC80142F
LONG TERM CARE
CA
01
—
LTC80382F
LONG TERM CARE
CA
Enumeration date
02/04/2007
Last updated
08/22/2020
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