Provider Demographics
NPI:1811468564
Name:3395493
Entity type:Organization
Organization Name:3395493
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DORSEY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:MARCHELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-900-0694
Mailing Address - Street 1:18340 YORBA LINDA BLVD # 443
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4058
Mailing Address - Country:US
Mailing Address - Phone:714-900-0694
Mailing Address - Fax:714-463-4403
Practice Address - Street 1:4458 VIA DEL VALLE
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-3021
Practice Address - Country:US
Practice Address - Phone:714-900-0694
Practice Address - Fax:714-463-4403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA306004719OtherRCFE
CA306004538OtherRCFE