MEDICARE: CALIFORNIA CONVALESCENT CENTER 1 INC

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	970000065	CA

General Provider Information

NPI Number	:	1164728143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA CONVALESCENT CENTER 1 INC

Provider Business Mailing Address
First Line	:	909 S LAKE ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2113
Country	:	US
Telephone Number	:	213-385-7301
Fax Number	:	213-385-0539

Provider Business Practice Location Address
First Line	:	909 S LAKE ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2113
Country	:	US
Telephone Number	:	213-385-7301
Fax Number	:	213-385-0539

Authorized Official
Title or Position	:	CORPORATE SECRETARY
Name	:	EVELYN BONIFACIO
Credential	:
Telephone Number	:	213-385-7301

Provider Enumeration Date	:	02/08/2011
Last Update Date	:	02/08/2011

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