Healthcare Provider Details

I. General information

NPI: 1588997431
Provider Name (Legal Business Name): COUNTRY VILLA SERVICE CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 W GOLDLEAF CIR STE 400
LOS ANGELES CA
90056-1297
US

IV. Provider business mailing address

5120 W GOLDLEAF CIR STE 400
LOS ANGELES CA
90056-1297
US

V. Phone/Fax

Practice location:
  • Phone: 310-574-3733
  • Fax:
Mailing address:
  • Phone: 310-574-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. CHERYL PETTERSON
Title or Position: VICE PRESIDENT - CAMS
Credential:
Phone: 310-574-3733