Provider Demographics
NPI:1487642336
Name:DEL RIO SANITARIUM, INC
Entity Type:Organization
Organization Name:DEL RIO SANITARIUM, INC
Other - Org Name:DEL RIO GARDENS CARE CENTER, DEL RIO SANITARIUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLALUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-927-6586
Mailing Address - Street 1:7004 E GAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-2014
Mailing Address - Country:US
Mailing Address - Phone:562-927-6586
Mailing Address - Fax:562-928-5097
Practice Address - Street 1:7004 E GAGE AVE
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-2014
Practice Address - Country:US
Practice Address - Phone:562-927-6586
Practice Address - Fax:562-928-5097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000053314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18080IMedicaid
CA206190235OtherOSHPD
CAZZT18080IMedicaid