Healthcare Provider Details

I. General information

NPI: 1801345772
Provider Name (Legal Business Name): LAKE MERRITT HEALTHCARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W LEMON AVE
MONROVIA CA
91016-2809
US

IV. Provider business mailing address

309 MACARTHUR BLVD
OAKLAND CA
94610-3233
US

V. Phone/Fax

Practice location:
  • Phone: 626-658-7344
  • Fax: 323-846-5788
Mailing address:
  • Phone: 510-836-3777
  • Fax: 510-371-6902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number020000061
License Number StateCA

VIII. Authorized Official

Name: CRYSTAL SOLORZANO
Title or Position: MANAGING MEMBER
Credential:
Phone: 323-836-9397