MEDICARE: BROADWATER RINALDI CARE CENTER, LLC

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	314000000X	Skilled Nursing Facility	920000057	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	:	1235272170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWATER RINALDI CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	16553 RINALDI ST
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-3762
Country	:	US
Telephone Number	:	818-360-1003
Fax Number	:	818-363-8913

Provider Business Practice Location Address
First Line	:	16553 RINALDI ST
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-3762
Country	:	US
Telephone Number	:	818-360-1003
Fax Number	:	818-363-8913

Authorized Official
Title or Position	:	MANAGER
Name	:	DOUGLAS EASTON
Credential	:
Telephone Number	:	818-368-1862

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	04/14/2009

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