Provider Demographics
NPI:1629560263
Name:MCLENNAN AVENUE HOME
Entity Type:Organization
Organization Name:MCLENNAN AVENUE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:323-253-5316
Mailing Address - Street 1:12325 MCLENNAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-1716
Mailing Address - Country:US
Mailing Address - Phone:818-886-3172
Mailing Address - Fax:747-300-9108
Practice Address - Street 1:12325 MCLENNAN AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-1716
Practice Address - Country:US
Practice Address - Phone:818-886-3172
Practice Address - Fax:747-300-9108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities