Provider Demographics
NPI:1770304792
Name:CITRUS BREEZE VILLA LLC
Entity type:Organization
Organization Name:CITRUS BREEZE VILLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:YOM
Authorized Official - Middle Name:
Authorized Official - Last Name:TEKESTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-423-4629
Mailing Address - Street 1:1009 S CITRUS ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-3403
Mailing Address - Country:US
Mailing Address - Phone:714-423-4629
Mailing Address - Fax:
Practice Address - Street 1:1009 S CITRUS ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-3403
Practice Address - Country:US
Practice Address - Phone:714-423-4629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility