Healthcare Provider Details

I. General information

NPI: 1750375705
Provider Name (Legal Business Name): COUNTRY VILLA WESTWOOD, A CA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12121 SANTA MONICA BLVD
LOS ANGELES CA
90025-2515
US

IV. Provider business mailing address

5120 W GOLDLEAF CIR SUITE 400
LOS ANGELES CA
90056-1292
US

V. Phone/Fax

Practice location:
  • Phone: 310-826-0821
  • Fax: 310-207-9311
Mailing address:
  • Phone: 310-574-3733
  • Fax: 310-574-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number910000123
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN E. REISSMAN
Title or Position: MANAGING MEMBER OF GENERAL PARTNER
Credential:
Phone: 310-574-3733