Healthcare Provider Details

I. General information

NPI: 1619560216
Provider Name (Legal Business Name): COMMUNITY CARE ON PALM RIVERSIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 02/15/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4768 PALM AVE
RIVERSIDE CA
92501-4012
US

IV. Provider business mailing address

1515 N FAIR OAKS AVE
PASADENA CA
91103-1808
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-9001
  • Fax: 951-367-0167
Mailing address:
  • Phone: 951-686-9001
  • Fax: 951-367-0167

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: EZRA BERCOVICH
Title or Position: MANAGER
Credential:
Phone: 213-948-0193