MEDICARE: INTERCOMMUNITY CARE CENTERS, INC.

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		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	:	1659424745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERCOMMUNITY CARE CENTERS, INC.

Provider Business Mailing Address
First Line	:	2626 GRAND AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-1707
Country	:	US
Telephone Number	:	562-427-8915
Fax Number	:	562-427-2348

Provider Business Practice Location Address
First Line	:	2626 GRAND AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-1707
Country	:	US
Telephone Number	:	562-427-8915
Fax Number	:	562-427-2348

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RUSSELL BOYDSTON
Credential	:
Telephone Number	:	562-427-8915

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	08/22/2020

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