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NPI Code Detail

MEDICARE: 803 HACIENDA LANE OPCO, LLC

MEDICARE: 803 HACIENDA LANE OPCO, 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1255288593
Entity Type Code : Organization
Provider Name (Legal Business Name) : 803 HACIENDA LANE OPCO, LLC
Provider Business Mailing Address
First Line : 9526 W PICO BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90035-1202
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 803 HACIENDA LN
Second Line :
City : BLOOMFIELD
State : NM
Zip : 87413-5109
Country : US
Telephone Number : 323-928-9445
Fax Number :
Authorized Official
Title or Position : EXECUTIVE VICE PRESIDENT
Name : AVROHOM TRESS
Credential :
Telephone Number : 323-928-9445
Provider Enumeration Date : 03/16/2026
Last Update Date : 03/16/2026

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