Provider Demographics
NPI:1083759500
Name:LAKEWOOD MANOR NORTH INC
Entity Type:Organization
Organization Name:LAKEWOOD MANOR NORTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-380-9175
Mailing Address - Street 1:831 S LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:USA
Mailing Address - Zip Code:USA
Mailing Address - Country:UM
Mailing Address - Phone:213-380-9175
Mailing Address - Fax:213-380-1879
Practice Address - Street 1:831 S LAKE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4013
Practice Address - Country:US
Practice Address - Phone:213-380-9175
Practice Address - Fax:213-380-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000069314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06078FMedicaid
CAZZT06078FMedicaid