Provider Demographics
NPI:1841463411
Name:CAROLDALE HOME
Entity type:Organization
Organization Name:CAROLDALE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:SAMBRANO
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-834-2106
Mailing Address - Street 1:23453 CAROLDALE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745
Mailing Address - Country:US
Mailing Address - Phone:310-834-2106
Mailing Address - Fax:310-513-9422
Practice Address - Street 1:23453 CAROLDALE AVENUE
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745
Practice Address - Country:US
Practice Address - Phone:310-834-2106
Practice Address - Fax:310-513-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1916712343104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness