Provider Demographics
NPI:1124380183
Name:CLAREMONT VILLA, INC.
Entity Type:Organization
Organization Name:CLAREMONT VILLA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARNIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVORGYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-596-0977
Mailing Address - Street 1:13290 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7252
Mailing Address - Country:US
Mailing Address - Phone:760-596-0977
Mailing Address - Fax:760-653-5161
Practice Address - Street 1:13290 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-7252
Practice Address - Country:US
Practice Address - Phone:760-596-0977
Practice Address - Fax:760-653-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002511314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124380183Medicaid