Healthcare Provider Details

I. General information

NPI: 1831186345
Provider Name (Legal Business Name): HOLLENBECK PALMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

573 S BOYLE AVE
LOS ANGELES CA
90033-3816
US

IV. Provider business mailing address

573 S BOYLE AVE
LOS ANGELES CA
90033-3816
US

V. Phone/Fax

Practice location:
  • Phone: 323-263-6195
  • Fax: 323-268-1248
Mailing address:
  • Phone: 323-263-6195
  • Fax: 323-780-3152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000076
License Number StateCA

VIII. Authorized Official

Name: MR. JOHNNY T YOUNG
Title or Position: CONTROLLER
Credential:
Phone: 323-263-6195