Healthcare Provider Details

I. General information

NPI: 1033106703
Provider Name (Legal Business Name): 1135 N LEISURE CT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 N LEISURE CT
ANAHEIM CA
92801-2939
US

IV. Provider business mailing address

4115 E BROADWAY
LONG BEACH CA
90803-1532
US

V. Phone/Fax

Practice location:
  • Phone: 714-772-1353
  • Fax: 714-490-2171
Mailing address:
  • Phone: 562-930-0777
  • Fax: 562-930-0728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number060000119
License Number StateCA

VIII. Authorized Official

Name: MS. ROSALIE PIACENTI SANCHEZ
Title or Position: MANAGER
Credential:
Phone: 562-930-0777