Provider Demographics
NPI:1669156709
Name:TYCOON RESIDENTIAL BOARD AND CARE
Entity type:Organization
Organization Name:TYCOON RESIDENTIAL BOARD AND CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:121-321-9135
Mailing Address - Street 1:10204 GERALD AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1132
Mailing Address - Country:US
Mailing Address - Phone:818-363-3418
Mailing Address - Fax:818-363-3418
Practice Address - Street 1:10204 GERALD AVE
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-1132
Practice Address - Country:US
Practice Address - Phone:818-363-3418
Practice Address - Fax:818-363-3418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility