Healthcare Provider Details

I. General information

NPI: 1689733453
Provider Name (Legal Business Name): HYDE PARK CONVALESCENT HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 WEST BLVD
LOS ANGELES CA
90043-4311
US

IV. Provider business mailing address

6520 WEST BLVD
LOS ANGELES CA
90043-4311
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-1354
  • Fax: 323-753-0509
Mailing address:
  • Phone: 323-753-1354
  • Fax: 323-753-0509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number910000066
License Number StateCA

VIII. Authorized Official

Name: MRS. ELAINE M WIESEL
Title or Position: ADMINISTRATOR
Credential:
Phone: 323-753-1354