Basic Information
Provider Information | |||||||||
NPI: | 1972744837 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAYWOOD SKILLED NURSING & WELLNESS CENTRE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAYWOOD HEALTHCARE & WELLNESS CENTRE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5967 W 3RD ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900362835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3236341940 | ||||||||
FaxNumber: | 3236341943 | ||||||||
Practice Location | |||||||||
Address1: | 6025 PINE AVE | ||||||||
Address2: |   | ||||||||
City: | MAYWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 902703108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3236341940 | ||||||||
FaxNumber: | 3236341943 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2009 | ||||||||
LastUpdateDate: | 10/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RECHNITZ | ||||||||
AuthorizedOfficialFirstName: | SHLOMO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6268001191 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 940000116 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | ZZT061401 | 05 | CA |   | MEDICAID |