Provider Demographics
NPI:1811680648
Name:K PRIME HOME LLC
Entity type:Organization
Organization Name:K PRIME HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:MARY JEAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:CATACUTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-677-3394
Mailing Address - Street 1:24302 BARK ST
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-5227
Mailing Address - Country:US
Mailing Address - Phone:949-462-0250
Mailing Address - Fax:949-462-0250
Practice Address - Street 1:24302 BARK ST
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-5227
Practice Address - Country:US
Practice Address - Phone:949-462-0250
Practice Address - Fax:949-462-0250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:K PRIME HOME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility