Provider Demographics
NPI:1477547024
Name:AG SAN GABRIEL, LLC
Entity Type:Organization
Organization Name:AG SAN GABRIEL, LLC
Other - Org Name:BROADWAY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-651-1808
Mailing Address - Street 1:112 EAST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776
Mailing Address - Country:US
Mailing Address - Phone:626-285-2165
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:112 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776
Practice Address - Country:US
Practice Address - Phone:626-285-2165
Practice Address - Fax:626-287-4061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000016314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05592IMedicaid
CA056201Medicare Oscar/Certification
CA056201Medicare ID - Type Unspecified