Healthcare Provider Details

I. General information

NPI: 1184620171
Provider Name (Legal Business Name): 22125 ROSCOE CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22125 ROSCOE BLVD
CANOGA PARK CA
91304-3839
US

IV. Provider business mailing address

22125 ROSCOE BLVD
CANOGA PARK CA
91304-3839
US

V. Phone/Fax

Practice location:
  • Phone: 818-883-7292
  • Fax: 818-883-9903
Mailing address:
  • Phone: 818-883-7292
  • Fax: 818-883-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number920000075
License Number StateCA

VIII. Authorized Official

Name: CARY BUCHMAN
Title or Position: PRESIDENT
Credential:
Phone: 818-905-8000