Provider Demographics
NPI:1356511836
Name:YELLO JACKET, INC.
Entity Type:Organization
Organization Name:YELLO JACKET, INC.
Other - Org Name:ELIZABETH COTTAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-271-8297
Mailing Address - Street 1:15739 SAN JOSE ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-7238
Mailing Address - Country:US
Mailing Address - Phone:818-892-6520
Mailing Address - Fax:
Practice Address - Street 1:15739 SAN JOSE ST
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-7238
Practice Address - Country:US
Practice Address - Phone:818-892-6520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility