1447244801 NPI number — COUNTRY VILLA SOUTH BAY, 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 1447244801 NPI number — COUNTRY VILLA SOUTH BAY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY VILLA SOUTH BAY, 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:
1447244801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5120 W GOLDLEAF CIR
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90056-1292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-574-3733
Provider Business Mailing Address Fax Number:
310-574-1322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 DOWNEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90805-4518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-634-4693
Provider Business Practice Location Address Fax Number:
562-630-2039
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REISSMAN
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
TRUSTEE OF MANAGING MEMBER
Authorized Official Telephone Number:
310-574-3733

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  940000011 , 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: ZZT06042J , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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