Provider Demographics
NPI:1033106703
Name:1135 N LEISURE CT INC
Entity Type:Organization
Organization Name:1135 N LEISURE CT INC
Other - Org Name:LEISURE COURT NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:PIACENTI
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-930-0777
Mailing Address - Street 1:4115 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-1532
Mailing Address - Country:US
Mailing Address - Phone:562-930-0777
Mailing Address - Fax:562-930-0728
Practice Address - Street 1:1135 N LEISURE CT
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2939
Practice Address - Country:US
Practice Address - Phone:714-772-1353
Practice Address - Fax:714-490-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-28
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000119314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55520GMedicaid
CA4981970001Medicare NSC
CA555520Medicare ID - Type Unspecified