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General NPI Number Information
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NPI Number | 1447244801
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Entity Type | Organization
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Legal Business Name | COUNTRY VILLA SOUTH BAY, LLC
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Dates
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Enumeration Date | 08/31/2005
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Last Update Date | 01/29/2014
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Provider Practice Location Address
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Address Line | 5901 DOWNEY AVE
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City | LONG BEACH
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State | CA
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Zip | 90805-4518
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Country | US
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Telephone | 562-634-4693
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Fax | 562-630-2039
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Provider Business Mailing Address
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Address Line | 5120 W GOLDLEAF CIR SUITE 400
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City | LOS ANGELES
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State | CA
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Zip | 90056-1292
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Country | US
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Telephone | 310-574-3733
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Fax | 310-574-1322
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Authorized Official
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Title or Position | TRUSTEE OF MANAGING MEMBER
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Name | MR. STEPHEN E. REISSMAN
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Credential |
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Telephone | 310-574-3733
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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 | 940000011
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License Number State | CA
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