Basic Information
| Provider Information | |||||||||
| NPI: | 1114338522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAPANESE HOME FOR THE AGED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KEIRO INTERMEDIATE CARE FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 325 S BOYLE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900333812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239807530 | ||||||||
| FaxNumber: | 3232632721 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 S BOYLE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900333812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239807530 | ||||||||
| FaxNumber: | 3232632721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIYAKE | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3239807500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 970000039 | CA | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC90079F | 05 | CA | MEDICAID |