Basic Information
| Provider Information | |||||||||
| NPI: | 1396031639 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME HEALTHCARE SERVICES-SHERMAN OAKS, LLC | ||||||||
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| OtherOrganizationName: | SHERMAN OAKS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E GUASTI RD | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917618655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092354400 | ||||||||
| FaxNumber: | 9092354419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4929 VAN NUYS BLVD | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189074540 | ||||||||
| FaxNumber: | 8189072829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | SCHELL | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL/SEC. | ||||||||
| AuthorizedOfficialTelephone: | 9092354311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 930000149 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | HSC30114I | 05 | CA | MEDICAID | HSC301141 | 05 | CA | MEDICAID |