Basic Information
| Provider Information | |||||||||
| NPI: | 1679567853 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRY VILLA PLAZA, A CA LTD. PARTNERSHIP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COUNTRY VILLA PLAZA HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5120 W GOLDLEAF CIR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900561292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105743733 | ||||||||
| FaxNumber: | 3105741322 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 HEMLOCK WAY | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927073609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145461966 | ||||||||
| FaxNumber: | 7145466719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REISSMAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060000168 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05206K | 05 | CA | MEDICAID |