Basic Information
| Provider Information | |||||||||
| NPI: | 1477547024 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AG SAN GABRIEL, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROADWAY HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 112 EAST BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262852165 | ||||||||
| FaxNumber: | 3105741322 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 EAST BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262852165 | ||||||||
| FaxNumber: | 6262874061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 07/21/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINTNER | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3236511808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 950000016 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05592I | 05 | CA | MEDICAID |