Provider Demographics
NPI:1093269946
Name:LA FUENTE LAVENDER LLC
Entity Type:Organization
Organization Name:LA FUENTE LAVENDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SOTERO
Authorized Official - Middle Name:CHANDLER
Authorized Official - Last Name:RAMAS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:909-346-0292
Mailing Address - Street 1:9545 TAMARIND AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5962
Mailing Address - Country:US
Mailing Address - Phone:909-346-0292
Mailing Address - Fax:909-346-0292
Practice Address - Street 1:9545 TAMARIND AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5962
Practice Address - Country:US
Practice Address - Phone:909-346-0292
Practice Address - Fax:909-346-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361800009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA361800009OtherRESIDENTIAL CARE FOR ELDERLY LICENSE NUMBER