Healthcare Provider Details

I. General information

NPI: 1548255284
Provider Name (Legal Business Name): 5648 EAST GOTHAM STREET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5648 GOTHAM ST
BELL GARDENS CA
90201-5413
US

IV. Provider business mailing address

5648 GOTHAM ST
BELL GARDENS CA
90201-5413
US

V. Phone/Fax

Practice location:
  • Phone: 562-927-2641
  • Fax: 562-927-4639
Mailing address:
  • Phone: 562-927-2641
  • Fax: 562-927-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CAROLINE L BOYER
Title or Position: DIRECTOR OF PATIENT ACCOUNTING
Credential:
Phone: 818-367-9546