MEDICARE: BROADWATER SUNRAY CARE CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	970000023	CA

General Provider Information

NPI Number	:	1023150042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWATER SUNRAY CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	3210 W PICO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3643
Country	:	US
Telephone Number	:	323-734-2171
Fax Number	:	323-734-1825

Provider Business Practice Location Address
First Line	:	3210 W PICO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3643
Country	:	US
Telephone Number	:	323-734-2171
Fax Number	:	323-734-1825

Authorized Official
Title or Position	:	MANAGER
Name	:	DOUGLAS EASTON
Credential	:
Telephone Number	:	818-368-1862

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	06/09/2008

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