Provider Demographics
NPI:1033554514
Name:COULSANDER JOHNSON CONCERN GERIATRIC CARE
Entity Type:Organization
Organization Name:COULSANDER JOHNSON CONCERN GERIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN
Authorized Official - Prefix:MISS
Authorized Official - First Name:COULSANSER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:562-230-3354
Mailing Address - Street 1:2090 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-4932
Mailing Address - Country:US
Mailing Address - Phone:562-230-3354
Mailing Address - Fax:
Practice Address - Street 1:539 E RHEA ST APT 4
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5542
Practice Address - Country:US
Practice Address - Phone:562-212-6835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251T00000X, 253Z00000X, 385H00000X
CAVN192615311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385H00000XRespite Care FacilityRespite Care