Provider Demographics
NPI:1225090947
Name:ELMCREST CARE CENTER, LLC
Entity Type:Organization
Organization Name:ELMCREST CARE CENTER, LLC
Other - Org Name:ELMCREST CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:3111 SANTA ANITA AVENUE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733
Mailing Address - Country:US
Mailing Address - Phone:626-443-0218
Mailing Address - Fax:626-443-4228
Practice Address - Street 1:3111 SANTA ANITA AVENUE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733
Practice Address - Country:US
Practice Address - Phone:626-443-0218
Practice Address - Fax:626-443-4228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-06
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05372KMedicaid
CAZZT05372KMedicaid