Provider Demographics
NPI:1114338522
Name:JAPANESE HOME FOR THE AGED
Entity Type:Organization
Organization Name:JAPANESE HOME FOR THE AGED
Other - Org Name:KEIRO INTERMEDIATE CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-980-7500
Mailing Address - Street 1:325 S BOYLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-3812
Mailing Address - Country:US
Mailing Address - Phone:323-980-7530
Mailing Address - Fax:323-263-2721
Practice Address - Street 1:325 S BOYLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-3812
Practice Address - Country:US
Practice Address - Phone:323-980-7530
Practice Address - Fax:323-263-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000039313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC90079FMedicaid
CA970000079Medicare Oscar/Certification
CA05A411Medicare Oscar/Certification