Provider Demographics
NPI:1508603986
Name:MONDELL PINE MANOR I
Entity type:Organization
Organization Name:MONDELL PINE MANOR I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-332-6150
Mailing Address - Street 1:1716 ERRINGER RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6506
Mailing Address - Country:US
Mailing Address - Phone:818-332-6150
Mailing Address - Fax:805-578-9486
Practice Address - Street 1:39046 MONDELL PINE AVE
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-6042
Practice Address - Country:US
Practice Address - Phone:818-332-6150
Practice Address - Fax:805-578-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility