Healthcare Provider Details

I. General information

NPI: 1699018739
Provider Name (Legal Business Name): COUNTRY VILLA IMPERIAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 E DEODAR ST
ONTARIO CA
91764-1309
US

IV. Provider business mailing address

933 E DEODAR ST
ONTARIO CA
91764-1309
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-2731
  • Fax: 909-985-1414
Mailing address:
  • Phone: 909-985-2731
  • Fax: 909-985-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number240000113
License Number StateCA

VIII. Authorized Official

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