Healthcare Provider Details

I. General information

NPI: 1104810159
Provider Name (Legal Business Name): COUNTRY VILLA SOUTH BAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13524 SHERMAN WAY
VAN NUYS CA
91405-2830
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 818-786-3470
  • Fax: 818-786-0943
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 Number
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN E. REISSMAN
Title or Position: TRUSTEE OF MANAGING MEMBER
Credential:
Phone: 310-574-3733