Basic Information
| Provider Information | |||||||||
| NPI: | 1023262029 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN MARINO SKILLED NURSING AND WELLNESS CENTRE | ||||||||
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| OtherOrganizationName: | SAN MARINO SKILLED NURSING AND WELLNESS CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5120 W GODLLEAF CIRCLE | ||||||||
| Address2: | 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105743733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2585 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264634105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | PETTERSON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. CAMS | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 970000088 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.