MEDICARE: 3535 OVERLAND AVE 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	310400000X	Assisted Living Facility	197606170	CA

General Provider Information

NPI Number	:	1538445499
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	3535 OVERLAND AVE LLC

Provider Business Mailing Address
First Line	:	3535 OVERLAND AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-5521
Country	:	US
Telephone Number	:	310-836-0510
Fax Number	:	310-836-1938

Provider Business Practice Location Address
First Line	:	3535 OVERLAND AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-5521
Country	:	US
Telephone Number	:	310-836-0510
Fax Number	:	310-836-1938

Authorized Official
Title or Position	:	LLC MANAGING MEMBER
Name	:	MARK STEVEN INGBER
Credential	:
Telephone Number	:	310-836-0510

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	10/24/2011

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