Provider Demographics
NPI:1548995541
Name:PROMISES GUEST VILLAGE, INC.
Entity type:Organization
Organization Name:PROMISES GUEST VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENCARNACION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-234-1148
Mailing Address - Street 1:1315 S ANAHEIM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6206
Mailing Address - Country:US
Mailing Address - Phone:714-774-1544
Mailing Address - Fax:714-635-0347
Practice Address - Street 1:1315 S ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6206
Practice Address - Country:US
Practice Address - Phone:714-774-1544
Practice Address - Fax:714-635-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA306000106OtherFACILITY LICENSE