Provider Demographics
NPI:1700555042
Name:COMMUNITY OF LA RECUPERATIVE CARE LLC
Entity Type:Organization
Organization Name:COMMUNITY OF LA RECUPERATIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, BSBM
Authorized Official - Phone:818-839-8911
Mailing Address - Street 1:13856 LOUVRE ST
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-3539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13856 LOUVRE ST
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-3539
Practice Address - Country:US
Practice Address - Phone:818-839-8911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY OF LA RECUPERATIVE CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA844572941OtherPRIVATE