Provider Demographics
NPI:1689650558
Name:THE VILLAGE MANOR HOSPICE
Entity Type:Organization
Organization Name:THE VILLAGE MANOR HOSPICE
Other - Org Name:VILLAGE VENTURES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:323-299-9499
Mailing Address - Street 1:3860 CRENSHAW BLVD
Mailing Address - Street 2:STE 219A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1816
Mailing Address - Country:US
Mailing Address - Phone:323-299-9499
Mailing Address - Fax:
Practice Address - Street 1:3860 CRENSHAW BLVD
Practice Address - Street 2:STE 219A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1816
Practice Address - Country:US
Practice Address - Phone:323-299-9499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHPC017047Medicaid
051704Medicare ID - Type Unspecified