Basic Information
| Provider Information | |||||||||
| NPI: | 1023019700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT. RUBIDOUX CONVALESCENT HOSPITAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5455 WILSHIRE BLVD | ||||||||
| Address2: | STE 1925 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236556960 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6401 33RD ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925091404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516812200 | ||||||||
| FaxNumber: | 9516814402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PLOTT TYLER | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3236556960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | J.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05581I | 05 | CA | MEDICAID |