Healthcare Provider Details

I. General information

NPI: 1891742946
Provider Name (Legal Business Name): SUNBRIDGE MEADOWBROOK REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3951 EAST BLVD
LOS ANGELES CA
90066-4605
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 310-391-8266
  • Fax: 310-390-9878
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number910000080
License Number StateCA

VIII. Authorized Official

Name: THOMAS DIVITORRIO
Title or Position: CFO, TREASURER, ASST SECRETARY
Credential:
Phone: 505-468-4742