Healthcare Provider Details

I. General information

NPI: 1952395147
Provider Name (Legal Business Name): COUNTRY VILLA NURSING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S ALVARADO ST
LOS ANGELES CA
90057-2915
US

IV. Provider business mailing address

5120 W GOLDLEAF CIR SUITE 400
LOS ANGELES CA
90056-1292
US

V. Phone/Fax

Practice location:
  • Phone: 213-484-9730
  • Fax: 213-484-9507
Mailing address:
  • Phone: 310-574-3733
  • Fax: 310-574-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000068
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN E. REISSMAN
Title or Position: PRESIDENT
Credential:
Phone: 310-574-3733