Basic Information
| Provider Information | |||||||||
| NPI: | 1811552359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ODELIA HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAMINO HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4525 WILSHIRE BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900103846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234053399 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1509 UNIVERSITY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052432257 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2019 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | GURWITZ | ||||||||
| AuthorizedOfficialFirstName: | SOLOMON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3234053399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.