Basic Information
| Provider Information | |||||||||
| NPI: | 1417273798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIRKSIDE FACILITIES OPERATIONS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6380 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900485003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236511808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6380 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900485003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236511808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 04/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | EASTON | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7023087191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.