1023019700 NPI number — MT. RUBIDOUX CONVALESCENT HOSPITAL, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023019700 NPI number — MT. RUBIDOUX CONVALESCENT HOSPITAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. RUBIDOUX CONVALESCENT HOSPITAL, 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:
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:
1023019700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5455 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
STE 1925
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90036-4201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-655-6960
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6401 33RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92509-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-681-2200
Provider Business Practice Location Address Fax Number:
951-681-4402
Provider Enumeration Date:
08/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PLOTT TYLER
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
323-655-6960

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: ZZT05581I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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