1316033087 NPI number — IMPERIAL CREST HEALTHCARE CENTER, LLC

Table of content: (NPI 1316033087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316033087 NPI number — IMPERIAL CREST HEALTHCARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPERIAL CREST HEALTHCARE CENTER, 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:
Provider Other Organization Name Type Code:
6
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:
1316033087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4032 WILSHIRE BLVD FL 6
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:
90010-3425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-389-6900
Provider Business Mailing Address Fax Number:
213-368-8560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11834 INGLEWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAWTHORNE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90250-0107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-679-1461
Provider Business Practice Location Address Fax Number:
310-679-2511
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
213-389-6900

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  910000054 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LTC55719F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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