1669552022 NPI number — GREEN ACRES LODGE LLC

Table of content: (NPI 1669552022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669552022 NPI number — GREEN ACRES LODGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREEN ACRES LODGE 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:
1669552022
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 FL 6
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:
626-280-5685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8101 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:
91770-4128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-280-2293
Provider Business Practice Location Address Fax Number:
626-280-5685
Provider Enumeration Date:
10/17/2006

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:  950000052 , 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: ZZT18146K , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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