Provider Demographics
NPI:1003249822
Name:CROFT LIVING HOME, INC.
Entity Type:Organization
Organization Name:CROFT LIVING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHADY
Authorized Official - Middle Name:
Authorized Official - Last Name:BORNA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:323-655-5060
Mailing Address - Street 1:458 N CROFT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2509
Mailing Address - Country:US
Mailing Address - Phone:323-655-5060
Mailing Address - Fax:323-651-1461
Practice Address - Street 1:458 N CROFT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-2509
Practice Address - Country:US
Practice Address - Phone:323-655-5060
Practice Address - Fax:323-651-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002351261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center