Healthcare Provider Details

I. General information

NPI: 1497512693
Provider Name (Legal Business Name): 13075 BLACKBIRD STREET OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13075 BLACKBIRD ST
GARDEN GROVE CA
92843-2902
US

IV. Provider business mailing address

9526 W PICO BLVD
LOS ANGELES CA
90035-1202
US

V. Phone/Fax

Practice location:
  • Phone: 714-530-6322
  • Fax:
Mailing address:
  • Phone: 310-730-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AVROHOM TRESS
Title or Position: MANAGER OF BOLD QUAIL 3 OPERATIONS
Credential:
Phone: 310-730-4800