Provider Demographics
NPI:1215011556
Name:SAN GABRIEL CONVALESCENT CENTER LLC
Entity Type:Organization
Organization Name:SAN GABRIEL CONVALESCENT CENTER LLC
Other - Org Name:SAN GABRIEL CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-389-6900
Mailing Address - Street 1:4032 WILSHIRE BLVD 6FL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3425
Mailing Address - Country:US
Mailing Address - Phone:213-389-6900
Mailing Address - Fax:626-280-0227
Practice Address - Street 1:8035 HILL DR
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4116
Practice Address - Country:US
Practice Address - Phone:626-280-4820
Practice Address - Fax:626-280-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000091314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC05181HMedicaid
CALTC05181HMedicaid