Provider Demographics
NPI:1780223503
Name:KP HEALTHCARE - DBA LOTUS VILLA MEMORY CARE
Entity Type:Organization
Organization Name:KP HEALTHCARE - DBA LOTUS VILLA MEMORY CARE
Other - Org Name:LOTUS VILLA & MEMORY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FELISA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-355-6887
Mailing Address - Street 1:9448 CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5512
Mailing Address - Country:US
Mailing Address - Phone:909-355-6887
Mailing Address - Fax:909-355-6882
Practice Address - Street 1:9448 CITRUS AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5512
Practice Address - Country:US
Practice Address - Phone:909-355-6887
Practice Address - Fax:909-355-6882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility