Healthcare Provider Details

I. General information

NPI: 1023150042
Provider Name (Legal Business Name): BROADWATER SUNRAY CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 W PICO BLVD
LOS ANGELES CA
90019-3643
US

IV. Provider business mailing address

3210 W PICO BLVD
LOS ANGELES CA
90019-3643
US

V. Phone/Fax

Practice location:
  • Phone: 323-734-2171
  • Fax: 323-734-1825
Mailing address:
  • Phone: 323-734-2171
  • Fax: 323-734-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000023
License Number StateCA

VIII. Authorized Official

Name: DOUGLAS EASTON
Title or Position: MANAGER
Credential:
Phone: 818-368-1862