Provider Demographics
NPI:1043204522
Name:AG MONROVIA, LLC
Entity Type:Organization
Organization Name:AG MONROVIA, LLC
Other - Org Name:MONROVIA GARDENS HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-651-1808
Mailing Address - Street 1:615 WEST DUARTE ROAD
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016
Mailing Address - Country:US
Mailing Address - Phone:626-358-4547
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:615 WEST DUARTE ROAD
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016
Practice Address - Country:US
Practice Address - Phone:626-358-4547
Practice Address - Fax:626-303-5788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000013314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05367IMedicaid
CA055367Medicare Oscar/Certification
CA055367Medicare ID - Type Unspecified