=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710605472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PICO RIVERA GARDENS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 08/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6525 ROSEMEAD BLVD
-----------------------------------------------------
City | PICO RIVERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90660-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-949-8489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6525 ROSEMEAD BLVD
-----------------------------------------------------
City | PICO RIVERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90660-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-949-8489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSEE
-----------------------------------------------------
Name | MORDECHAI STOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-949-8489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------