Provider Demographics
NPI:1902268758
Name:HEALTHY LIFE CONGREGATE CARE
Entity Type:Organization
Organization Name:HEALTHY LIFE CONGREGATE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:V
Authorized Official - Last Name:DERDERYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-955-0057
Mailing Address - Street 1:3011 NORTH PEORIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063
Mailing Address - Country:US
Mailing Address - Phone:805-955-0057
Mailing Address - Fax:805-728-7454
Practice Address - Street 1:3011 PEORIA AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-1654
Practice Address - Country:US
Practice Address - Phone:805-955-0057
Practice Address - Fax:805-728-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility