Basic Information
| Provider Information | |||||||||
| NPI: | 1790854180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLDWATER CARE CENTER LLC | ||||||||
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| OtherOrganizationName: | SHERMAN VILLAGE HEALTHCARE 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: | 12750 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | N HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916073319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187666105 | ||||||||
| FaxNumber: | 8187669102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2133896900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 920000059 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT06159M | 05 | CA | MEDICAID | LTC70105F | 05 | CA | MEDICAID |