Healthcare Provider Details

I. General information

NPI: 1801827738
Provider Name (Legal Business Name): SOUTH FORK HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 FOUNTAIN AVE
LOS ANGELES CA
90029-1007
US

IV. Provider business mailing address

5400 FOUNTAIN AVE
LOS ANGELES CA
90029-1007
US

V. Phone/Fax

Practice location:
  • Phone: 323-461-4301
  • Fax: 323-461-2784
Mailing address:
  • Phone: 323-461-4301
  • Fax: 323-461-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHEILAH GRIER
Title or Position: AR DIRECTOR
Credential:
Phone: 323-461-4301