Basic Information
| Provider Information | |||||||||
| NPI: | 1528148020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PICO RIVERA HEALTHCARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PICO RIVERA HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4032 WILSHIRE BLVD FL6 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900103425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133896900 | ||||||||
| FaxNumber: | 2133688560 | ||||||||
| Practice Location | |||||||||
| Address1: | 9140 VERNER ST | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906602741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629481961 | ||||||||
| FaxNumber: | 5629495998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2133896900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 940000281 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1528148020 | 05 | CA | MEDICAID |