Provider Demographics
NPI:1447244801
Name:COUNTRY VILLA SOUTH BAY, LLC
Entity Type:Organization
Organization Name:COUNTRY VILLA SOUTH BAY, LLC
Other - Org Name:COUNTRY VILLA BAY VISTA HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRUSTEE OF MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:REISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:5120 W GOLDLEAF CIR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1292
Mailing Address - Country:US
Mailing Address - Phone:310-574-3733
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:5901 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-4518
Practice Address - Country:US
Practice Address - Phone:562-634-4693
Practice Address - Fax:562-630-2039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000011314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06042JMedicaid
CA056042Medicare ID - Type Unspecified