Provider Demographics
NPI:1275026957
Name:VALLEY VISTA RESIDENTIAL MANOR LLC
Entity Type:Organization
Organization Name:VALLEY VISTA RESIDENTIAL MANOR LLC
Other - Org Name:VALLEY MANOR GUEST HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:PO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-648-2737
Mailing Address - Street 1:6130 VINELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4914
Mailing Address - Country:US
Mailing Address - Phone:949-648-2737
Mailing Address - Fax:949-608-1588
Practice Address - Street 1:6130 VINELAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4914
Practice Address - Country:US
Practice Address - Phone:818-766-8161
Practice Address - Fax:818-643-8753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness