Provider Demographics
NPI:1912357120
Name:ANGELS ASSISTED LIVING
Entity Type:Organization
Organization Name:ANGELS ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALADIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-532-3623
Mailing Address - Street 1:16627 CANYON LAKE LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8024 REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1640
Practice Address - Country:US
Practice Address - Phone:909-371-3966
Practice Address - Fax:909-371-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA366426788OtherCOMMUNITY CARE LICENSING