Provider Demographics
NPI:1598174484
Name:CRYSTAL CARE VILLA
Entity Type:Organization
Organization Name:CRYSTAL CARE VILLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-255-6659
Mailing Address - Street 1:6410 EL REPOSO STREET
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-2352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6410 EL REPOSO STREET
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-2352
Practice Address - Country:US
Practice Address - Phone:760-366-3845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility