Healthcare Provider Details

I. General information

NPI: 1801126305
Provider Name (Legal Business Name): COUNTRY VILLA EAST, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 W PICO BLVD
LOS ANGELES CA
90035-2647
US

IV. Provider business mailing address

3580 WILSHIRE BLVD STE 600
LOS ANGELES CA
90010-2502
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-5565
  • Fax: 323-782-9516
Mailing address:
  • Phone: 323-330-6500
  • 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: MRS. CHERYL PETTERSON
Title or Position: VICE PRESIDENT - CAMS
Credential:
Phone: 310-574-3733