1114291523 NPI number — 1100 SOUTH ALVARADO STREET, LLC

Table of content: (NPI 1114291523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114291523 NPI number — 1100 SOUTH ALVARADO STREET, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1100 SOUTH ALVARADO STREET, 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:
OLYMPIA CONVALESCENT HOSPITAL
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:
1114291523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 S ALVARADO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90006-4110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-487-3000
Provider Business Mailing Address Fax Number:
213-487-1909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S ALVARADO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90006-4110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-487-3000
Provider Business Practice Location Address Fax Number:
213-487-1909
Provider Enumeration Date:
03/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WEISS
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
818-385-3200

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)

  • Identifier: 1114291523 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05-6321 . This is a "MEDICARE ID - TYPE UNSPECIFIED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZT18570G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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