Healthcare Provider Details

I. General information

NPI: 1134101348
Provider Name (Legal Business Name): MANCHESTER MANOR CONVALESCENT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 W MANCHESTER AVE
LOS ANGELES CA
90044-4913
US

IV. Provider business mailing address

837 W MANCHESTER AVE
LOS ANGELES CA
90044-4913
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-1789
  • Fax: 323-753-0400
Mailing address:
  • Phone: 323-753-1789
  • Fax: 323-753-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number970000032
License Number StateCA

VIII. Authorized Official

Name: MRS. DELORES J JOHNSON RN
Title or Position: OWNER/DIRECTOR OF NURSING
Credential: RN
Phone: 323-753-1789