Healthcare Provider Details

I. General information

NPI: 1588651194
Provider Name (Legal Business Name): 14857 ROSCOE BLVD CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14857 ROSCOE BLVD
PANORAMA CITY CA
91402-4617
US

IV. Provider business mailing address

4115 E BROADWAY
LONG BEACH CA
90803-1532
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-5707
  • Fax: 818-894-8151
Mailing address:
  • Phone: 562-930-0777
  • Fax: 562-930-0728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number920000072
License Number StateCA

VIII. Authorized Official

Name: ROSALIE PIACENTI SANCHEZ
Title or Position: MANAGER
Credential:
Phone: 562-930-0777