Provider Demographics
NPI:1497578330
Name:KNOLLS WEST ASSISTED LIVING, LLC.
Entity type:Organization
Organization Name:KNOLLS WEST ASSISTED LIVING, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRONSAY
Authorized Official - Middle Name:ELYSE
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:760-245-0107
Mailing Address - Street 1:16890 GREEN TREE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5618
Mailing Address - Country:US
Mailing Address - Phone:760-245-0107
Mailing Address - Fax:760-843-1861
Practice Address - Street 1:16890 GREEN TREE BLVD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5618
Practice Address - Country:US
Practice Address - Phone:760-245-0107
Practice Address - Fax:760-843-1861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-07
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility