Provider Demographics
NPI:1306028527
Name:LIFEHOUSE CYPRESS OPERATIONS, LLC
Entity Type:Organization
Organization Name:LIFEHOUSE CYPRESS OPERATIONS, LLC
Other - Org Name:CYPRESS HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-337-1929
Mailing Address - Street 1:1000 CORPORATE POINTE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7690
Mailing Address - Country:US
Mailing Address - Phone:310-337-1929
Mailing Address - Fax:
Practice Address - Street 1:1633 CYPRESS LN
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-2823
Practice Address - Country:US
Practice Address - Phone:530-877-9316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEHOUSE HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-29
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING APPROVAL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA055494Medicare Oscar/Certification
055494Medicare Oscar/Certification