Provider Demographics
NPI:1831264092
Name:JHA GERIATRIC SERVICES, INC
Entity type:Organization
Organization Name:JHA GERIATRIC SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-757-4447
Mailing Address - Street 1:7150 TAMPA AVE
Mailing Address - Street 2:ATTN. FISCAL DEPT.
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3700
Mailing Address - Country:US
Mailing Address - Phone:818-774-3000
Mailing Address - Fax:
Practice Address - Street 1:18855 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:818-774-3354
Practice Address - Fax:818-757-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000928261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70641FMedicaid
CACMM70641FMedicaid