Provider Demographics
NPI:1679781884
Name:L. MARILLAC GROUP HOME
Entity Type:Organization
Organization Name:L. MARILLAC GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-821-3698
Mailing Address - Street 1:23711 PROSPECT VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1637
Mailing Address - Country:US
Mailing Address - Phone:909-821-3698
Mailing Address - Fax:909-860-7614
Practice Address - Street 1:23711 PROSPECT VALLEY DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1637
Practice Address - Country:US
Practice Address - Phone:909-821-3698
Practice Address - Fax:909-860-7614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities