Provider Demographics
NPI:1083959423
Name:EAST HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:EAST HEALTHCARE CENTER, LLC
Other - Org Name:COUNTRY VILLA EAST NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP BUSINESS SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-596-2145
Mailing Address - Street 1:2415 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-2608
Mailing Address - Country:US
Mailing Address - Phone:323-734-1101
Mailing Address - Fax:323-734-3872
Practice Address - Street 1:2415 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-2608
Practice Address - Country:US
Practice Address - Phone:323-734-1101
Practice Address - Fax:323-734-3872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000018314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06114HMedicaid
CA056114Medicare Oscar/Certification