Provider Demographics
NPI:1225028327
Name:COMMUNITY CONVALESCENT HOSPITAL OF LA MESA LP
Entity Type:Organization
Organization Name:COMMUNITY CONVALESCENT HOSPITAL OF LA MESA LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-556-0040
Mailing Address - Street 1:8665 LA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3903
Mailing Address - Country:US
Mailing Address - Phone:619-465-0702
Mailing Address - Fax:619-828-1782
Practice Address - Street 1:8665 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941
Practice Address - Country:US
Practice Address - Phone:619-465-0702
Practice Address - Fax:619-828-1782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090000033314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18070GMedicaid
CA055873Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID