Healthcare Provider Details

I. General information

NPI: 1992921571
Provider Name (Legal Business Name): MGH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 W 101ST ST
LOS ANGELES CA
90044-1801
US

IV. Provider business mailing address

1202 W 101ST ST
LOS ANGELES CA
90044-1802
US

V. Phone/Fax

Practice location:
  • Phone: 323-754-9051
  • Fax: 323-754-8832
Mailing address:
  • Phone: 323-754-1408
  • Fax: 323-754-8832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: STEPHANIE WEATHERSBY
Title or Position: SECRETARY
Credential:
Phone: 323-754-1408