Basic Information
| Provider Information | |||||||||
| NPI: | 1235130915 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEL ROSA VILLA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5455 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 1925 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236556960 | ||||||||
| FaxNumber: | 3236557122 | ||||||||
| Practice Location | |||||||||
| Address1: | 2018 DEL ROSA AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098853261 | ||||||||
| FaxNumber: | 9098883871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | TYLER | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | PLOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3236556960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | J.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 240000029 | CA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 240000029 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 55-5195 | 01 | CA | MEDICARE ID-TYPE UNSPECIFIED | OTHER | LTC90017G | 05 | CA | MEDICAID |