Healthcare Provider Details

I. General information

NPI: 1194767871
Provider Name (Legal Business Name): FOUNTAIN VIEW SUBACUTE & NURSING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 FOUNTAIN AVE
LOS ANGELES CA
90029-1005
US

IV. Provider business mailing address

5310 FOUNTAIN AVE
LOS ANGELES CA
90029-1005
US

V. Phone/Fax

Practice location:
  • Phone: 323-461-9961
  • Fax: 323-461-6854
Mailing address:
  • Phone: 323-461-9961
  • Fax: 323-461-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000008
License Number StateCA

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752