Provider Demographics
NPI:1134101348
Name:MANCHESTER MANOR CONVALESCENT HOSPITAL
Entity Type:Organization
Organization Name:MANCHESTER MANOR CONVALESCENT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR OF NURSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON RN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:323-753-1789
Mailing Address - Street 1:837 W MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4913
Mailing Address - Country:US
Mailing Address - Phone:323-753-1789
Mailing Address - Fax:323-753-0400
Practice Address - Street 1:837 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4913
Practice Address - Country:US
Practice Address - Phone:323-753-1789
Practice Address - Fax:323-753-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000032310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55273FOtherLTC PROVIDER NUMBER
CA555273Medicare Oscar/Certification
CA555273Medicare Oscar/Certification