MEDICARE: 14857 ROSCOE BLVD CORPORATION

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	920000072	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	:	1588651194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	14857 ROSCOE BLVD CORPORATION

Provider Business Mailing Address
First Line	:	4115 E BROADWAY
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-1532
Country	:	US
Telephone Number	:	562-930-0777
Fax Number	:	562-930-0728

Provider Business Practice Location Address
First Line	:	14857 ROSCOE BLVD
Second Line	:
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-4617
Country	:	US
Telephone Number	:	818-894-5707
Fax Number	:	818-894-8151

Authorized Official
Title or Position	:	MANAGER
Name	:	ROSALIE PIACENTI SANCHEZ
Credential	:
Telephone Number	:	562-930-0777

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	12/08/2010

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