Basic Information
| Provider Information | |||||||||
| NPI: | 1891051355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELMONT HEIGHTS HEALTHCARE CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY VILLA BELMONT HEIGHTS HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5120 W GOLDLEAF CIR STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900561297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235962145 | ||||||||
| FaxNumber: | 3235964645 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908042011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235962145 | ||||||||
| FaxNumber: | 3235964645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2012 | ||||||||
| LastUpdateDate: | 02/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | REISSMAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 940000082 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC70129F | 05 | CA | MEDICAID | ZZT05077H | 05 | CA | MEDICAID |