=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245277334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN GROVE MEDICAL INVESTORS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 12/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12332 GARDEN GROVE BLVD
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92843-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-534-1041
-----------------------------------------------------
Fax | 714-534-7921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 KEITH ST NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-473-5751
-----------------------------------------------------
Fax | 423-339-8342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY
-----------------------------------------------------
Name | CINDY CROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-473-5867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 6000018
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------