1215011556 NPI number — SAN GABRIEL CONVALESCENT CENTER 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 1215011556 NPI number — SAN GABRIEL CONVALESCENT CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN GABRIEL CONVALESCENT 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:
1215011556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4032 WILSHIRE BLVD 6FL
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:
626-280-0227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8035 HILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEMEAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91770-4116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-280-4820
Provider Business Practice Location Address Fax Number:
626-280-0227
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  950000091 , 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: LTC05181H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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