Provider Demographics
NPI:1144050519
Name:ANTELOPE VALLEY MANOR INC
Entity type:Organization
Organization Name:ANTELOPE VALLEY MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-332-6150
Mailing Address - Street 1:1716 ERRINGER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6527
Mailing Address - Country:US
Mailing Address - Phone:818-332-6150
Mailing Address - Fax:
Practice Address - Street 1:2801 HUSTON PL
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-1803
Practice Address - Country:US
Practice Address - Phone:661-726-1869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility