Basic Information
| Provider Information | |||||||||
| NPI: | 1699018739 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRY VILLA IMPERIAL, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALTHCARE CENTER OF BELLA VISTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 E DEODAR ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917641309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099852731 | ||||||||
| FaxNumber: | 9099851414 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 E DEODAR ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917641309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099852731 | ||||||||
| FaxNumber: | 9099851414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | REISSMAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 240000113 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05693I | 05 | CA | MEDICAID |