Healthcare Provider Details

I. General information

NPI: 1225637994
Provider Name (Legal Business Name): RG LEGACY II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 N FAIR OAKS AVE
PASADENA CA
91103-1822
US

IV. Provider business mailing address

1570 N FAIR OAKS AVE
PASADENA CA
91103-1822
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-0558
  • Fax: 626-798-8240
Mailing address:
  • Phone: 626-798-1111
  • Fax: 626-374-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: EZEQUIEL BERCOVICH
Title or Position: MANAGER
Credential:
Phone: 213-948-0793