Provider Demographics
NPI:1699321109
Name:SUNRISE MANOR COMMON LOVELY, LLC
Entity type:Organization
Organization Name:SUNRISE MANOR COMMON LOVELY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SLIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-304-5960
Mailing Address - Street 1:1635 COCHRAN ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1635 COCHRAN ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2160
Practice Address - Country:US
Practice Address - Phone:805-304-5960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility