MEDICARE: 5648 EAST GOTHAM STREET 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		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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548255284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5648 EAST GOTHAM STREET LLC

Provider Business Mailing Address
First Line	:	5648 GOTHAM ST
Second Line	:
City	:	BELL GARDENS
State	:	CA
Zip	:	90201-5413
Country	:	US
Telephone Number	:	562-927-2641
Fax Number	:	562-927-4639

Provider Business Practice Location Address
First Line	:	5648 GOTHAM ST
Second Line	:
City	:	BELL GARDENS
State	:	CA
Zip	:	90201-5413
Country	:	US
Telephone Number	:	562-927-2641
Fax Number	:	562-927-4639

Authorized Official
Title or Position	:	DIRECTOR OF PATIENT ACCOUNTING
Name	:	CAROLINE L BOYER
Credential	:
Telephone Number	:	818-367-9546

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	08/22/2020

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