Provider Demographics
NPI:1629948641
Name:PORTSMOUTH SENIOR HOME LLC
Entity type:Organization
Organization Name:PORTSMOUTH SENIOR HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE FIDES
Authorized Official - Middle Name:
Authorized Official - Last Name:LAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-309-1158
Mailing Address - Street 1:1060 E LURAY ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-1020
Mailing Address - Country:US
Mailing Address - Phone:951-309-1158
Mailing Address - Fax:
Practice Address - Street 1:28611 PORTSMOUTH DR
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-2658
Practice Address - Country:US
Practice Address - Phone:951-309-1158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility