Healthcare Provider Details

I. General information

NPI: 1487754297
Provider Name (Legal Business Name): KEIRO NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 LINCOLN PARK AVE
LOS ANGELES CA
90031
US

IV. Provider business mailing address

2221 LINCOLN PARK AVE
LOS ANGELES CA
90031
US

V. Phone/Fax

Practice location:
  • Phone: 323-276-5700
  • Fax: 323-276-5732
Mailing address:
  • Phone: 323-276-5700
  • Fax: 323-276-5732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000059
License Number StateCA

VIII. Authorized Official

Name: MR. SHAWN MIYAKE
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 323-980-7500