Provider Demographics
NPI:1851720486
Name:CONGREGATE LIVING HEALTH FACILITY, INC.
Entity Type:Organization
Organization Name:CONGREGATE LIVING HEALTH FACILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:805-253-6708
Mailing Address - Street 1:5440 TUJUNGA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-4967
Mailing Address - Country:US
Mailing Address - Phone:805-253-6708
Mailing Address - Fax:888-640-4414
Practice Address - Street 1:5440 TUJUNGA AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-4967
Practice Address - Country:US
Practice Address - Phone:805-253-6708
Practice Address - Fax:888-640-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility