Basic Information
| Provider Information | |||||||||
| NPI: | 1245894872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TULARE LAKE POST ACUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 W LEMON AVE | ||||||||
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| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910162809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238369397 | ||||||||
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| Practice Location | |||||||||
| Address1: | 604 E MERRITT AVE | ||||||||
| Address2: | |||||||||
| City: | TULARE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932742135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596861601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOLORZANO | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6266587344 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASSEMBLY HEALTH GROUP LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 056261 | 01 | CA | MEDICARE PTAN | OTHER | ZZT062611 | 05 | CA | MEDICAID | 1316011851 | 05 | CA | MEDICAID |