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General NPI Number Information
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NPI Number | 1184055956
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Entity Type | Organization
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Legal Business Name | SRSW LLC
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Dates
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Enumeration Date | 12/04/2013
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Last Update Date | 05/30/2017
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Provider Practice Location Address
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Address Line | 919 N SUNSET AVE
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City | WEST COVINA
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State | CA
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Zip | 91790-1244
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Country | US
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Telephone | 949-445-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 4 S STONINGTON RD
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City | LAGUNA BEACH
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State | CA
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Zip | 92651-6741
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Country | US
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Telephone | 949-445-1000
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | SPENCER ROBERT SAMUELIAN
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Credential |
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Telephone | 949-445-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State | CA
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