1295084440 NPI number — WINDSOR PALM VALLEY, LLC

Table of content: (NPI 1295084440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295084440 NPI number — WINDSOR PALM VALLEY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINDSOR PALM VALLEY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PALM VALLEY REHABILITATION & CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295084440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9200 W SUNSET BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90069-3502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-385-1076
Provider Business Mailing Address Fax Number:
310-595-3736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13575 W MCDOWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-536-9911
Provider Business Practice Location Address Fax Number:
623-536-9502
Provider Enumeration Date:
09/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SAMSON
Authorized Official First Name:
LEE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER, WINDSOR OMG HOLDIN
Authorized Official Telephone Number:
310-385-1090

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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