1477659399 NPI number — GARDEN PARK CARE 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 1477659399 NPI number — GARDEN PARK CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN PARK CARE 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:
1477659399
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:
3050 SATURN ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92821-6278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-577-3880
Provider Business Mailing Address Fax Number:
714-577-3895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12681 HASTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-971-2153
Provider Business Practice Location Address Fax Number:
714-750-6913
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORTENSEN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SR VP FINANCE
Authorized Official Telephone Number:
714-577-3880

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: LTC55667F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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