Provider Demographics
NPI:1114969540
Name:KNOTT AVENUE CARE CENTER, INC.
Entity Type:Organization
Organization Name:KNOTT AVENUE CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-497-7330
Mailing Address - Street 1:3075 E THOUSAND OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3402
Mailing Address - Country:US
Mailing Address - Phone:805-497-7330
Mailing Address - Fax:805-497-7440
Practice Address - Street 1:9021 KNOTT AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-4138
Practice Address - Country:US
Practice Address - Phone:714-826-2330
Practice Address - Fax:714-527-6869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC70154FMedicaid
CAZZT05674IMedicaid
CA05-5674Medicare ID - Type Unspecified