Basic Information
Provider Information | |||||||||
NPI: | 1710469663 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROUTE 66 POST ACUTE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 W LEMON AVE | ||||||||
Address2: |   | ||||||||
City: | MONROVIA | ||||||||
State: | CA | ||||||||
PostalCode: | 910162809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238369397 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 638 E COLORADO AVE | ||||||||
Address2: |   | ||||||||
City: | GLENDORA | ||||||||
State: | CA | ||||||||
PostalCode: | 917404422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269636091 | ||||||||
FaxNumber: | 6263354415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2018 | ||||||||
LastUpdateDate: | 09/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SOLORZANO | ||||||||
AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6263460300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 950000026 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | ZZT05676G | 05 | CA |   | MEDICAID |