1205839081 NPI number — INDUSTRY CONVALESCENT HOSPITAL

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 1205839081 NPI number — INDUSTRY CONVALESCENT HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDUSTRY CONVALESCENT HOSPITAL
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:
EL ENCANTO HEALTHCARE & HABILITATION 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:
1205839081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 S. EL ENCANTO ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CITY OF INDUSTRY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-336-1274
Provider Business Mailing Address Fax Number:
626-330-2789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 S. EL ENCANTO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CITY OF INDUSTRY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-336-1274
Provider Business Practice Location Address Fax Number:
626-330-2789
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CALVO
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
626-336-1274

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  960000747 , 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: ZZT18646G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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