Provider Demographics
NPI:1568679959
Name:MARY'S HOUSE
Entity Type:Organization
Organization Name:MARY'S HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-739-3585
Mailing Address - Street 1:14901 CONDON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1216
Mailing Address - Country:US
Mailing Address - Phone:310-739-3585
Mailing Address - Fax:310-675-4551
Practice Address - Street 1:14901 CONDON AVE
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1216
Practice Address - Country:US
Practice Address - Phone:310-739-3585
Practice Address - Fax:310-675-4551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY INVESTMENTS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-17
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000992315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA156867995901OtherMEDI-CAL