MEDICARE: GREENFIELD COUNTRY CLUB

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		CA

General Provider Information

NPI Number	:	1811984065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENFIELD COUNTRY CLUB

Provider Business Mailing Address
First Line	:	1937 PONTIUS AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-5611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	369 E PINE ST
Second Line	:
City	:	BISHOP
State	:	CA
Zip	:	93514-2849
Country	:	US
Telephone Number	:	760-873-3100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENQ H CHEN
Credential	:
Telephone Number	:	310-889-9929

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	08/22/2020

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Directions to “GREENFIELD COUNTRY CLUB ” Practice Location

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