Provider Demographics
NPI:1356747059
Name:LEADWELL CARE HOME, INC.
Entity type:Organization
Organization Name:LEADWELL CARE HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:LOVELY
Authorized Official - Middle Name:DADIVAS
Authorized Official - Last Name:ONG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:818-625-8874
Mailing Address - Street 1:17256 LEADWELL ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2537
Mailing Address - Country:US
Mailing Address - Phone:818-625-8874
Mailing Address - Fax:
Practice Address - Street 1:17256 LEADWELL ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-2537
Practice Address - Country:US
Practice Address - Phone:818-625-8874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002447315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities