Basic Information
| Provider Information | |||||||||
| NPI: | 1932370343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIMAS RETIREMENT CENTER, INC. | ||||||||
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| OtherOrganizationName: | SAN DIMAS RETIREMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4032 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900103405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133896900 | ||||||||
| FaxNumber: | 2134803372 | ||||||||
| Practice Location | |||||||||
| Address1: | 834 W ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917732418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095998441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
| AuthorizedOfficialFirstName: | IRA | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2133896900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 191500609 | CA | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.