Provider Demographics
NPI:1174861108
Name:LEISURE CARE HOME CARE AGENCY, INC
Entity Type:Organization
Organization Name:LEISURE CARE HOME CARE AGENCY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACKANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-363-7401
Mailing Address - Street 1:30131 TOWN CENTER DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2034
Mailing Address - Country:US
Mailing Address - Phone:949-363-7401
Mailing Address - Fax:949-363-7419
Practice Address - Street 1:30131 TOWN CENTER DR
Practice Address - Street 2:SUITE 205
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2034
Practice Address - Country:US
Practice Address - Phone:949-363-7401
Practice Address - Fax:949-363-7419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC-2616981311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home