Provider Demographics
NPI:1316499536
Name:EVERETT FOREST,LLC
Entity type:Organization
Organization Name:EVERETT FOREST,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSEE AND ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:SWANSON
Authorized Official - Last Name:GALASINAO
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:909-799-3170
Mailing Address - Street 1:11350 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3519
Mailing Address - Country:US
Mailing Address - Phone:909-799-3170
Mailing Address - Fax:909-799-1381
Practice Address - Street 1:11350 POPLAR ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3519
Practice Address - Country:US
Practice Address - Phone:909-799-3170
Practice Address - Fax:909-799-1381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366410695310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility