Healthcare Provider Details

I. General information

NPI: 1801406772
Provider Name (Legal Business Name): PINE FOREST HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13922 CERISE AVE
HAWTHORNE CA
90250-8118
US

IV. Provider business mailing address

13922 CERISE AVE
HAWTHORNE CA
90250-8118
US

V. Phone/Fax

Practice location:
  • Phone: 310-675-3304
  • Fax: 310-675-4389
Mailing address:
  • Phone: 310-675-3304
  • Fax: 310-675-4389

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: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249