Provider Demographics
NPI:1255152229
Name:INGOMAR CONGREGATE LIVING HEALTH FACILITY
Entity type:Organization
Organization Name:INGOMAR CONGREGATE LIVING HEALTH FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VAHAGN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-403-1803
Mailing Address - Street 1:19000 INGOMAR ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-1717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19000 INGOMAR ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-1717
Practice Address - Country:US
Practice Address - Phone:818-403-1803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility