Provider Demographics
NPI:1598584500
Name:THE PROVIDENCE MANOR, LLC
Entity type:Organization
Organization Name:THE PROVIDENCE MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN NALANGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LIMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-680-0844
Mailing Address - Street 1:3434 TAMARISK DR
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-2561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3434 TAMARISK DR
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-2561
Practice Address - Country:US
Practice Address - Phone:323-680-0844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility