Provider Demographics
NPI:1790325439
Name:FOUNTAIN VALLEY SENIOR HOMES LLC
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY SENIOR HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ULDARICO
Authorized Official - Middle Name:BANAGAN
Authorized Official - Last Name:ALMIRANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-290-6006
Mailing Address - Street 1:18561 SANTA ISADORA ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6212
Mailing Address - Country:US
Mailing Address - Phone:657-464-9805
Mailing Address - Fax:
Practice Address - Street 1:18561 SANTA ISADORA ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6212
Practice Address - Country:US
Practice Address - Phone:657-464-9805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNTAIN VALLEY SENIOR HOMES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA306005441OtherCCLD