Healthcare Provider Details

I. General information

NPI: 1912248972
Provider Name (Legal Business Name): BRIGHTON CONVALESCENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 N FAIR OAKS AVE
PASADENA CA
91103-1619
US

IV. Provider business mailing address

1836 N FAIR OAKS AVE
PASADENA CA
91103-1619
US

V. Phone/Fax

Practice location:
  • Phone: 626-512-2595
  • Fax: 626-794-2964
Mailing address:
  • Phone: 626-798-9124
  • Fax: 626-794-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000194
License Number StateCA

VIII. Authorized Official

Name: CIPRIANO BAUTISTA
Title or Position: MEMBER
Credential:
Phone: 626-512-2595