MEDICARE: COUNTRY VILLA IMPERIAL 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	970000041	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	:	1083608293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY VILLA IMPERIAL LLC

Provider Business Mailing Address
First Line	:	5120 W GOLDLEAF CIR
Second Line	:	SUITE 400
City	:	LOS ANGELES
State	:	CA
Zip	:	90056-1292
Country	:	US
Telephone Number	:	310-574-3733
Fax Number	:	310-574-1322

Provider Business Practice Location Address
First Line	:	3002 ROWENA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-2005
Country	:	US
Telephone Number	:	323-666-1544
Fax Number	:	323-666-9584

Authorized Official
Title or Position	:	TRUSTEE OF MANAGING MEMBER
Name	:	MR. STEPHEN E. REISSMAN
Credential	:
Telephone Number	:	310-574-3733

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	01/29/2014

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Directions to “COUNTRY VILLA IMPERIAL LLC ” Practice Location

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