Provider Demographics
NPI:1447224381
Name:OUR LADY OF GUADALUPE
Entity Type:Organization
Organization Name:OUR LADY OF GUADALUPE
Other - Org Name:MJV HEALTH CARE CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:805-487-9757
Mailing Address - Street 1:2311 E CHEVY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-1811
Mailing Address - Country:US
Mailing Address - Phone:805-487-9757
Mailing Address - Fax:805-487-9757
Practice Address - Street 1:1474 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2205
Practice Address - Country:US
Practice Address - Phone:805-487-9757
Practice Address - Fax:805-487-9757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60799FMedicaid