Provider Demographics
NPI:1710395777
Name:EAGLE GLEN CARE HOME LLC
Entity Type:Organization
Organization Name:EAGLE GLEN CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:RESTITUTO
Authorized Official - Middle Name:
Authorized Official - Last Name:CALILUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-906-6046
Mailing Address - Street 1:1697 HONORS CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-0757
Mailing Address - Country:US
Mailing Address - Phone:951-582-9230
Mailing Address - Fax:951-340-2740
Practice Address - Street 1:1697 HONORS CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883-0757
Practice Address - Country:US
Practice Address - Phone:951-582-9230
Practice Address - Fax:951-340-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336426012310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility