MEDICARE: MANCHESTER MANOR 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	310400000X	Assisted Living Facility	970000032	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LTC55273F	OTHER	CA	LTC PROVIDER NUMBER

General Provider Information

NPI Number	:	1134101348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANCHESTER MANOR CONVALESCENT HOSPITAL

Provider Business Mailing Address
First Line	:	837 W MANCHESTER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-4913
Country	:	US
Telephone Number	:	323-753-1789
Fax Number	:	323-753-0400

Provider Business Practice Location Address
First Line	:	837 W MANCHESTER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-4913
Country	:	US
Telephone Number	:	323-753-1789
Fax Number	:	323-753-0400

Authorized Official
Title or Position	:	OWNER/DIRECTOR OF NURSING
Name	:	MRS. DELORES J JOHNSON RN
Credential	:	RN
Telephone Number	:	323-753-1789

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	03/31/2016

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Directions to “MANCHESTER MANOR CONVALESCENT HOSPITAL ” Practice Location

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