Provider Demographics
NPI:1366991135
Name:LEISURE VILLAGE INC
Entity type:Organization
Organization Name:LEISURE VILLAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:AHANKOOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-585-2200
Mailing Address - Street 1:6728 GAVIOTA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5944
Mailing Address - Country:US
Mailing Address - Phone:818-585-2200
Mailing Address - Fax:818-387-6445
Practice Address - Street 1:6728 GAVIOTA AVE
Practice Address - Street 2:
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-5944
Practice Address - Country:US
Practice Address - Phone:818-585-2200
Practice Address - Fax:818-387-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197607543310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility