Basic Information
| Provider Information | |||||||||
| NPI: | 1952395147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTRY VILLA NURSING CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNTRY VILLA REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5120 W GOLDLEAF CIR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900561292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105743733 | ||||||||
| FaxNumber: | 3105741322 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 S ALVARADO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900572915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134849730 | ||||||||
| FaxNumber: | 2134849507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | REISSMAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 970000068 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC90020G | 05 | CA | MEDICAID |