Healthcare Provider Details

I. General information

NPI: 1437789252
Provider Name (Legal Business Name): MIRACLE MILE HEALTHCARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S FAIRFAX AVE
LOS ANGELES CA
90019-4401
US

IV. Provider business mailing address

107 W LEMON AVE
MONROVIA CA
91016-2809
US

V. Phone/Fax

Practice location:
  • Phone: 323-938-2451
  • Fax:
Mailing address:
  • Phone: 626-658-7344
  • Fax:

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: PHILLIP CHASE
Title or Position: MANAGER
Credential:
Phone: 626-658-7344