Basic Information
| Provider Information | |||||||||
| NPI: | 1255526513 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFEHOUSE MACLAY OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MACLAY HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 329 NORTH REAL ROAD | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933091820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613277107 | ||||||||
| FaxNumber: | 6613271152 | ||||||||
| Practice Location | |||||||||
| Address1: | 12831 MACLAY ST | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913424934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183614455 | ||||||||
| FaxNumber: | 8188371180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDRIOTTI | ||||||||
| AuthorizedOfficialFirstName: | LOU | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3103371929 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFEHOUSE HEALTH SERVICES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.