MEDICARE: MOUNTAINSIDE OPERATING COMPANY, 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	240000136	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	:	1477547750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAINSIDE OPERATING COMPANY, 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	:	1311 E DATE ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4233
Country	:	US
Telephone Number	:	909-882-3316
Fax Number	:	909-882-5126

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	:	02/04/2014

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