Basic Information
| Provider Information | |||||||||
| NPI: | 1033458237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOS FELIZ HEALTHCARE CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY VILLA LOS FELIZ HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3002 ROWENA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900392005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236661544 | ||||||||
| FaxNumber: | 3236669584 | ||||||||
| Practice Location | |||||||||
| Address1: | 3002 ROWENA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900392005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236661544 | ||||||||
| FaxNumber: | 3236669584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2013 | ||||||||
| LastUpdateDate: | 02/07/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETTERSON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3235962145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 970000041 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT18588J | 05 | CA | MEDICAID |