MEDICARE: ELM PARK, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	960001105	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215076062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELM PARK, INC

Provider Business Mailing Address
First Line	:	3351 E IMPERIAL HWY
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-3305
Country	:	US
Telephone Number	:	310-638-6691
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 LOS FLORES BLVD
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-2927
Country	:	US
Telephone Number	:	310-638-6691
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KATHERINE LANCE
Credential	:	MHA
Telephone Number	:	310-638-6691

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	09/11/2013

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