MEDICARE: KEIRO NURSING HOME

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	970000059	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	:	1487754297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEIRO NURSING HOME

Provider Business Mailing Address
First Line	:	2221 LINCOLN PARK AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031
Country	:	US
Telephone Number	:	323-276-5700
Fax Number	:	323-276-5732

Provider Business Practice Location Address
First Line	:	2221 LINCOLN PARK AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031
Country	:	US
Telephone Number	:	323-276-5700
Fax Number	:	323-276-5732

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	MR. SHAWN MIYAKE
Credential	:
Telephone Number	:	323-980-7500

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/11/2013

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Directions to “KEIRO NURSING HOME ” Practice Location

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