Provider Demographics
NPI:1104681600
Name:EASTLAKE VILLA INC
Entity type:Organization
Organization Name:EASTLAKE VILLA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEXLIER
Authorized Official - Middle Name:CASAS
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-400-4341
Mailing Address - Street 1:591 ARLENE DR
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3518
Mailing Address - Country:US
Mailing Address - Phone:831-228-1207
Mailing Address - Fax:831-851-0080
Practice Address - Street 1:591 ARLENE DR
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3518
Practice Address - Country:US
Practice Address - Phone:831-228-1207
Practice Address - Fax:831-851-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility