Basic Information
Provider Information | |||||||||
NPI: | 1154592467 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IRA DAVID ENTERPRISES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CROFTON MANOR INN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4032 WILSHIRE BLVD | ||||||||
Address2: | SUITE 600 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900103405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2133896900 | ||||||||
FaxNumber: | 2134803372 | ||||||||
Practice Location | |||||||||
Address1: | 1950 E 5TH ST | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908022023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624370093 | ||||||||
FaxNumber: | 5624369987 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2008 | ||||||||
LastUpdateDate: | 04/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
AuthorizedOfficialFirstName: | IRA | ||||||||
AuthorizedOfficialMiddleName: | DAVID | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2133896900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 191671691 | CA | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.