MEDICARE: CULVER WEST CONVALESCENT HOSPITAL

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	910000038	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083603880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CULVER WEST CONVALESCENT HOSPITAL

Provider Business Mailing Address
First Line	:	4035 GRAND VIEW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5211
Country	:	US
Telephone Number	:	310-390-9506
Fax Number	:	310-391-1974

Provider Business Practice Location Address
First Line	:	4035 GRAND VIEW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5211
Country	:	US
Telephone Number	:	310-390-9506
Fax Number	:	310-391-1974

Authorized Official
Title or Position	:	ADMINISTRATOR IN TRAINING
Name	:	MR. BRYON EUGENE MOONEY JR.
Credential	:	ADMIN IN TRAINING
Telephone Number	:	310-390-9506

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	05/29/2012

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