Provider Demographics
NPI:1376328088
Name:AVISTA SENIOR LIVING MANAGEMENT, LLC
Entity Type:Organization
Organization Name:AVISTA SENIOR LIVING MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE-LOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-737-1600
Mailing Address - Street 1:737 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3168
Mailing Address - Country:US
Mailing Address - Phone:951-737-1600
Mailing Address - Fax:
Practice Address - Street 1:737 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3168
Practice Address - Country:US
Practice Address - Phone:951-737-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility