Healthcare Provider Details

I. General information

NPI: 1649041195
Provider Name (Legal Business Name): 1338 20TH STREET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 20TH ST
SANTA MONICA CA
90404-2034
US

IV. Provider business mailing address

12642 HATTERAS ST
VALLEY VILLAGE CA
91607-1525
US

V. Phone/Fax

Practice location:
  • Phone: 310-255-2800
  • Fax:
Mailing address:
  • Phone: 213-948-0193
  • Fax:

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: 213-948-0193