Healthcare Provider Details

I. General information

NPI: 1083759500
Provider Name (Legal Business Name): LAKEWOOD MANOR NORTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 S LAKE ST
LOS ANGELES CA
90057-4013
US

IV. Provider business mailing address

831 S LAKE STREET
LOS ANGELES USA
USA
UM

V. Phone/Fax

Practice location:
  • Phone: 213-380-9175
  • Fax: 213-380-1879
Mailing address:
  • Phone: 213-380-9175
  • Fax: 213-380-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000069
License Number StateCA

VIII. Authorized Official

Name: MR. KIM CHARLES ELLIOTT
Title or Position: ADMINISTRATOR
Credential:
Phone: 213-380-9175