Provider Demographics
NPI:1457457384
Name:HERITAGE MANOR HEALTHCARE LLC
Entity Type:Organization
Organization Name:HERITAGE MANOR HEALTHCARE LLC
Other - Org Name:HERITAGE MANOR HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-577-3880
Mailing Address - Street 1:3050 SATURN STREET
Mailing Address - Street 2:SUITE #201
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6278
Mailing Address - Country:US
Mailing Address - Phone:714-577-3880
Mailing Address - Fax:714-577-3895
Practice Address - Street 1:610 N GARFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754
Practice Address - Country:US
Practice Address - Phone:626-573-3141
Practice Address - Fax:626-571-8461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT059891Medicaid
CAZZT059891Medicaid