Provider Demographics
NPI:1619225570
Name:ECLC WAKE FOREST VILLA, INC.
Entity Type:Organization
Organization Name:ECLC WAKE FOREST VILLA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELITA
Authorized Official - Middle Name:FRANCO
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:714-434-9489
Mailing Address - Street 1:233 WAKE FOREST RD.
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-6446
Mailing Address - Country:US
Mailing Address - Phone:714-434-9489
Mailing Address - Fax:949-642-0622
Practice Address - Street 1:233 WAKE FOREST RD.
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6446
Practice Address - Country:US
Practice Address - Phone:714-434-9489
Practice Address - Fax:949-642-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306001960311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility