Basic Information
| Provider Information | |||||||||
| NPI: | 1164457644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOLDSTAR HEALTHCARE CENTER OF CHATSWORTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDSTAR HEALTHCARE CENTER OF CHATSWORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21820 CRAGGY VIEW ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913112909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188828233 | ||||||||
| FaxNumber: | 8188822269 | ||||||||
| Practice Location | |||||||||
| Address1: | 21820 CRAGGY VIEW ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913112909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188828233 | ||||||||
| FaxNumber: | 8188822269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | GOLDNER | ||||||||
| AuthorizedOfficialFirstName: | DOV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3235565959 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OWNER | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 920000019 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC90074F | 05 | CA | MEDICAID |