Provider Demographics
NPI:1013063841
Name:CANYON HOME II
Entity Type:Organization
Organization Name:CANYON HOME II
Other - Org Name:CANYON HOMES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:DENOGEAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:818-353-8214
Mailing Address - Street 1:10712 ARTRUDE ST
Mailing Address - Street 2:
Mailing Address - City:SHADOW HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91040-1314
Mailing Address - Country:US
Mailing Address - Phone:818-353-8214
Mailing Address - Fax:818-273-4479
Practice Address - Street 1:8611 WENTWORTH
Practice Address - Street 2:
Practice Address - City:SUNLAND
Practice Address - State:CA
Practice Address - Zip Code:91040
Practice Address - Country:US
Practice Address - Phone:818-353-1514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001001315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60809FMedicaid