Provider Demographics
NPI:1053168971
Name:BIC BRAIN INJURY HOME AT BANNER AVE
Entity type:Organization
Organization Name:BIC BRAIN INJURY HOME AT BANNER AVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:GENDRON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ARF, CBIS
Authorized Official - Phone:805-482-1312
Mailing Address - Street 1:50 BANNER AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1551
Mailing Address - Country:US
Mailing Address - Phone:805-482-1312
Mailing Address - Fax:805-456-7876
Practice Address - Street 1:50 BANNER AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1551
Practice Address - Country:US
Practice Address - Phone:805-482-1312
Practice Address - Fax:805-456-7876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAIN INJURY CENTER OF VENTURA COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility