Basic Information
| Provider Information | |||||||||
| NPI: | 1457457384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE MANOR HEALTHCARE LLC | ||||||||
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| OtherOrganizationName: | HERITAGE MANOR HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 SATURN STREET | ||||||||
| Address2: | SUITE #201 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928216278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145773880 | ||||||||
| FaxNumber: | 7145773895 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 N GARFIELD AVENUE | ||||||||
| Address2: | |||||||||
| City: | MONTEREY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265733141 | ||||||||
| FaxNumber: | 6265718461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORTENSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7145773880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT059891 | 05 | CA | MEDICAID |