Provider Demographics
NPI:1568236040
Name:BLIND MOOSE LLC
Entity Type:Organization
Organization Name:BLIND MOOSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE LLC MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-702-6922
Mailing Address - Street 1:23 CORPORATE PLAZA DR STE 150-88
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7911
Mailing Address - Country:US
Mailing Address - Phone:562-702-6922
Mailing Address - Fax:
Practice Address - Street 1:12697 BURBANK RD
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-3362
Practice Address - Country:US
Practice Address - Phone:562-702-6922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility