Provider Demographics
NPI:1376759209
Name:LADY OF GRACE, INC
Entity Type:Organization
Organization Name:LADY OF GRACE, INC
Other - Org Name:SAN FERNANDO VALLEY ADULT DAY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:TUMARU
Authorized Official - Last Name:PAJE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-831-6651
Mailing Address - Street 1:10351 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-7318
Mailing Address - Country:US
Mailing Address - Phone:818-831-6651
Mailing Address - Fax:818-831-9822
Practice Address - Street 1:10351 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-7318
Practice Address - Country:US
Practice Address - Phone:818-831-6651
Practice Address - Fax:818-831-9822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70150FMedicaid