Provider Demographics
NPI:1235130915
Name:DEL ROSA VILLA, LLC
Entity Type:Organization
Organization Name:DEL ROSA VILLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:PLOTT
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:323-655-6960
Mailing Address - Street 1:5455 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1925
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4201
Mailing Address - Country:US
Mailing Address - Phone:323-655-6960
Mailing Address - Fax:323-655-7122
Practice Address - Street 1:2018 DEL ROSA AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5642
Practice Address - Country:US
Practice Address - Phone:909-885-3261
Practice Address - Fax:909-888-3871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000029313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-5195OtherMEDICARE ID-TYPE UNSPECIFIED
CALTC90017GMedicaid