Provider Demographics
NPI:1083603880
Name:CULVER WEST CONVALESCENT HOSPITAL
Entity Type:Organization
Organization Name:CULVER WEST CONVALESCENT HOSPITAL
Other - Org Name:CULVER WEST CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR IN TRAINING
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYON
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:ADMIN IN TRAINING
Authorized Official - Phone:310-390-9506
Mailing Address - Street 1:4035 GRAND VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5211
Mailing Address - Country:US
Mailing Address - Phone:310-390-9506
Mailing Address - Fax:310-391-1974
Practice Address - Street 1:4035 GRAND VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5211
Practice Address - Country:US
Practice Address - Phone:310-390-9506
Practice Address - Fax:310-391-1974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA910000038314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05350GMedicaid
CA0690140001Medicare NSC
CA055350Medicare Oscar/Certification