Provider Demographics
NPI:1053480418
Name:BROADWAY MANOR CARE CENTER LLC
Entity Type:Organization
Organization Name:BROADWAY MANOR CARE CENTER LLC
Other - Org Name:BROADWAY MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-389-6900
Mailing Address - Street 1:4032 WILSHIRE BLVD FL 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3425
Mailing Address - Country:US
Mailing Address - Phone:213-389-6900
Mailing Address - Fax:818-246-7635
Practice Address - Street 1:605 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1007
Practice Address - Country:US
Practice Address - Phone:818-246-7174
Practice Address - Fax:818-246-7635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA920000064314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05670JMedicaid
CA055670Medicare ID - Type Unspecified