Provider Demographics
NPI:1518007970
Name:IMPERIAL PARK, INC
Entity Type:Organization
Organization Name:IMPERIAL PARK, INC
Other - Org Name:WEST PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:310-638-6691
Mailing Address - Street 1:3351 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3305
Mailing Address - Country:US
Mailing Address - Phone:310-638-6691
Mailing Address - Fax:
Practice Address - Street 1:3323 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3305
Practice Address - Country:US
Practice Address - Phone:310-638-6691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001047315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80240FMedicaid