Basic Information
| Provider Information | |||||||||
| NPI: | 1679657993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHEA HEALTHCARE CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WHITTIER PACIFIC CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4032 WILSHIRE BLVD FL 6 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900103425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133896900 | ||||||||
| FaxNumber: | 2133688560 | ||||||||
| Practice Location | |||||||||
| Address1: | 7716 PICKERING AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906022001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626935240 | ||||||||
| FaxNumber: | 5626962192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | SANDOVAL | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 2133896900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 940000149 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05764H | 05 | CA | MEDICAID | LTC70113G | 05 | CA | MEDICAID |