Healthcare Provider Details

I. General information

NPI: 1487706628
Provider Name (Legal Business Name): BONNIE BRAE CONVALESCENT HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S BONNIE BRAE ST
LOS ANGELES CA
90057-3010
US

IV. Provider business mailing address

420 S BONNIE BRAE ST
LOS ANGELES CA
90057-3010
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-8144
  • Fax: 213-483-6145
Mailing address:
  • Phone: 213-483-8144
  • Fax: 213-483-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000062
License Number StateCA

VIII. Authorized Official

Name: MISS ELMA B. CAYTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 213-483-8144