Healthcare Provider Details

I. General information

NPI: 1033554514
Provider Name (Legal Business Name): COULSANDER JOHNSON CONCERN GERIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 E RHEA ST APT 4
LONG BEACH CA
90806-5542
US

IV. Provider business mailing address

2090 MYRTLE AVE
LONG BEACH CA
90806-4932
US

V. Phone/Fax

Practice location:
  • Phone: 562-212-6835
  • Fax:
Mailing address:
  • Phone: 562-230-3354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberVN192615
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MISS COULSANSER JOHNSON
Title or Position: LVN
Credential: LVN
Phone: 562-230-3354