Provider Demographics
NPI:1346677192
Name:VILLA REDONDO CARE HOME INC
Entity Type:Organization
Organization Name:VILLA REDONDO CARE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TALAVERA
Authorized Official - Last Name:BOLONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-434-9932
Mailing Address - Street 1:237 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5951
Mailing Address - Country:US
Mailing Address - Phone:562-434-9931
Mailing Address - Fax:
Practice Address - Street 1:237 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-5951
Practice Address - Country:US
Practice Address - Phone:562-434-9931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198204399310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility