Provider Demographics
NPI:1497517973
Name:LEISURE GROVE, LLC
Entity Type:Organization
Organization Name:LEISURE GROVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ATLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-475-1800
Mailing Address - Street 1:4221 WILSHIRE BLVD STE 392
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3537
Mailing Address - Country:US
Mailing Address - Phone:323-475-1800
Mailing Address - Fax:323-475-1826
Practice Address - Street 1:413 E CYPRESS ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-3334
Practice Address - Country:US
Practice Address - Phone:818-244-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility