Healthcare Provider Details

I. General information

NPI: 1669775326
Provider Name (Legal Business Name): 1450 NORTH FAIR OAKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N FAIR OAKS AVE
PASADENA CA
91103-1801
US

IV. Provider business mailing address

1450 N FAIR OAKS AVE
PASADENA CA
91103-1801
US

V. Phone/Fax

Practice location:
  • Phone: 626-791-1948
  • Fax: 626-791-9282
Mailing address:
  • Phone: 626-791-1948
  • Fax: 626-791-9282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000082
License Number StateCA

VIII. Authorized Official

Name: DR. JOSEMAR MERCADO
Title or Position: MANAGING MEMBER
Credential:
Phone: 626-305-0281