Healthcare Provider Details

I. General information

NPI: 1639548449
Provider Name (Legal Business Name): AGVA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15115 S VERMONT AVE
GARDENA CA
90247-4101
US

IV. Provider business mailing address

15115 S VERMONT AVE
GARDENA CA
90247-4101
US

V. Phone/Fax

Practice location:
  • Phone: 310-532-0700
  • Fax: 310-532-0001
Mailing address:
  • Phone: 310-532-0700
  • Fax: 310-532-0001

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: MR. JEFFREY BRADSHAW
Title or Position: MANAGER
Credential:
Phone: 949-347-7100