Healthcare Provider Details

I. General information

NPI: 1386270916
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA SPECIALTY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14900 IMPERIAL HWY
LA MIRADA CA
90638-2172
US

IV. Provider business mailing address

14900 IMPERIAL HWY
LA MIRADA CA
90638-2172
US

V. Phone/Fax

Practice location:
  • Phone: 562-944-1900
  • Fax: 562-777-3600
Mailing address:
  • Phone: 562-944-1900
  • Fax: 562-777-3600

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: TERRANCE DILLON
Title or Position: AUTHORIZED OFFICIAL / SECRETARY
Credential:
Phone: 502-596-7220