Provider Demographics
NPI:1841662038
Name:WHITE OAK CONGREGATE LIVING FACILITY, LLC
Entity type:Organization
Organization Name:WHITE OAK CONGREGATE LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-272-6666
Mailing Address - Street 1:11847 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2754
Mailing Address - Country:US
Mailing Address - Phone:310-272-6666
Mailing Address - Fax:
Practice Address - Street 1:9301 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2336
Practice Address - Country:US
Practice Address - Phone:818-885-1135
Practice Address - Fax:818-885-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550003205320700000X
251J00000X, 311Z00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No251J00000XAgenciesNursing Care
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility