Basic Information
| Provider Information | |||||||||
| NPI: | 1336164151 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHA HOLLYWOOD MEDICAL CENTER LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOLYYWOOD PRESBYTERIAN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134133000 | ||||||||
| FaxNumber: | 3236600446 | ||||||||
| Practice Location | |||||||||
| Address1: | 4636 FOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900291830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239134830 | ||||||||
| FaxNumber: | 3239134552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 04/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | RIVERS | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 3239134914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | LTC70045G | 05 | CA | MEDICAID | ZZT06311G | 05 | CA | MEDICAID |