Provider Demographics
NPI:1720335789
Name:FRONT PORCH COMMUNITIES OPERATING GROUP LLC
Entity Type:Organization
Organization Name:FRONT PORCH COMMUNITIES OPERATING GROUP LLC
Other - Org Name:FREDERICKA MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-254-4100
Mailing Address - Street 1:800 N BRAND BLVD FL 19
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1231
Mailing Address - Country:US
Mailing Address - Phone:818-254-4100
Mailing Address - Fax:818-254-4101
Practice Address - Street 1:111 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-1822
Practice Address - Country:US
Practice Address - Phone:619-427-2777
Practice Address - Fax:619-427-0394
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRONT PORCH COMMUNITIES AND SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-09
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA055354Medicare Oscar/Certification