Basic Information
| Provider Information | |||||||||
| NPI: | 1447297171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAUREL GROVE HOSPITAL-REHAB UNIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748373 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900748373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553981633 | ||||||||
| FaxNumber: | 5108696592 | ||||||||
| Practice Location | |||||||||
| Address1: | 19933 LAKE CHABOT RD | ||||||||
| Address2: | |||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945464003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105821730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | TRENT | ||||||||
| AuthorizedOfficialTitleorPosition: | VP SHARED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9162978555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDEN MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 140000030 | CA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | HSP30095J | 05 | CA | MEDICAID |