Healthcare Provider Details

I. General information

NPI: 1164728143
Provider Name (Legal Business Name): CALIFORNIA CONVALESCENT CENTER 1 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 S LAKE ST
LOS ANGELES CA
90006-2113
US

IV. Provider business mailing address

909 S LAKE ST
LOS ANGELES CA
90006-2113
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-7301
  • Fax: 213-385-0539
Mailing address:
  • Phone: 213-385-7301
  • Fax: 213-385-0539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000065
License Number StateCA

VIII. Authorized Official

Name: EVELYN BONIFACIO
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 213-385-7301