Provider Demographics
NPI:1477280931
Name:CRYSTAL GARDEN RCFE LLC
Entity Type:Organization
Organization Name:CRYSTAL GARDEN RCFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:EBADPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-999-0995
Mailing Address - Street 1:13224 IROQUOIS RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-6384
Mailing Address - Country:US
Mailing Address - Phone:213-999-0995
Mailing Address - Fax:
Practice Address - Street 1:13224 IROQUOIS RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-6384
Practice Address - Country:US
Practice Address - Phone:213-999-0995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility