Healthcare Provider Details

I. General information

NPI: 1447882782
Provider Name (Legal Business Name): GOLDEN STATE RECUPERATIVE CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 E. 110TH ST
LOS ANGELES CA
90061
US

IV. Provider business mailing address

153 E. 110TH ST
LOS ANGELES CA
90061
US

V. Phone/Fax

Practice location:
  • Phone: 323-475-1126
  • Fax: 323-475-1132
Mailing address:
  • Phone: 323-475-1126
  • Fax: 323-475-1132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL GONZALEZ
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 323-475-1127