Provider Demographics
NPI:1063893006
Name:KOLES PLACE INC
Entity type:Organization
Organization Name:KOLES PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NEEKOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASPIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-462-2730
Mailing Address - Street 1:8630 RAYFORD DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3512
Mailing Address - Country:US
Mailing Address - Phone:310-670-6965
Mailing Address - Fax:424-227-6024
Practice Address - Street 1:8630 RAYFORD DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3512
Practice Address - Country:US
Practice Address - Phone:310-670-6965
Practice Address - Fax:424-227-6024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC 60731FMedicaid