Healthcare Provider Details

I. General information

NPI: 1538153572
Provider Name (Legal Business Name): COUNTRY VILLA EAST, L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9655 SEPULVEDA BLVD
NORTH HILLS CA
91343-3307
US

IV. Provider business mailing address

400 EXCHANGE STE 140
IRVINE CA
92602-1343
US

V. Phone/Fax

Practice location:
  • Phone: 818-892-8665
  • Fax: 818-891-1208
Mailing address:
  • Phone: 714-673-6870
  • Fax: 949-954-6373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number920000065
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN E. REISSMAN
Title or Position: MANAGING MEMBER OF GENERAL PARTNER
Credential:
Phone: 310-574-3733