MEDICARE: MIRACLE MILE POST ACUTE 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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	555139	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1457903338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE MILE POST ACUTE LLC

Provider Business Mailing Address
First Line	:	107 W LEMON AVE
Second Line	:
City	:	MONROVIA
State	:	CA
Zip	:	91016-2809
Country	:	US
Telephone Number	:	626-346-0300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 S FAIRFAX AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-4401
Country	:	US
Telephone Number	:	323-938-2451
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CRYSTAL SOLORZANO
Credential	:
Telephone Number	:	626-346-0300

Provider Enumeration Date	:	07/11/2019
Last Update Date	:	07/11/2019

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