Basic Information
| Provider Information | |||||||||
| NPI: | 1609132927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TERRACE HEALTHCARE CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TERRACE HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5120 W GOLDLEAF CIR STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900561297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235962145 | ||||||||
| FaxNumber: | 3235964645 | ||||||||
| Practice Location | |||||||||
| Address1: | 6070 W PICO BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900352647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236533980 | ||||||||
| FaxNumber: | 3236532885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | REISSMAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 910000144 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05119G | 05 | CA | MEDICAID |