Healthcare Provider Details

I. General information

NPI: 1003600800
Provider Name (Legal Business Name): QUINCY MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N CHESTER AVE
COMPTON CA
90221-2701
US

IV. Provider business mailing address

115 N CHESTER AVE
COMPTON CA
90221-2701
US

V. Phone/Fax

Practice location:
  • Phone: 313-106-3599
  • Fax:
Mailing address:
  • Phone: 313-106-3599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. XAVIER COSTOLINO HOGAN SR.
Title or Position: OWNER
Credential:
Phone: 562-450-7211