Healthcare Provider Details

I. General information

NPI: 1265433957
Provider Name (Legal Business Name): WATERMAN CONVALESCENT HOSPITAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N WATERMAN AVE
SAN BERNARDINO CA
92404-4831
US

IV. Provider business mailing address

5455 WILSHIRE BLVD STE 1925
LOS ANGELES CA
90036-4201
US

V. Phone/Fax

Practice location:
  • Phone: 909-882-1215
  • Fax: 909-881-2071
Mailing address:
  • Phone: 323-655-6960
  • Fax: 323-655-7122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ELIZABETH PLOTT TYLER
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential: J.D.
Phone: 323-655-6960