Healthcare Provider Details

I. General information

NPI: 1679567853
Provider Name (Legal Business Name): COUNTRY VILLA PLAZA, A CA LTD. PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 HEMLOCK WAY
SANTA ANA CA
92707-3609
US

IV. Provider business mailing address

5120 W GOLDLEAF CIR SUITE 400
LOS ANGELES CA
90056-1292
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-1966
  • Fax: 714-546-6719
Mailing address:
  • Phone: 310-574-3733
  • Fax: 310-574-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number060000168
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN E. REISSMAN
Title or Position: PRESIDENT OF GENERAL PARTNER
Credential:
Phone: 310-574-3733