Provider Demographics
NPI:1518737691
Name:4545 SHELLEY COURT OPCO, LLC
Entity Type:Organization
Organization Name:4545 SHELLEY COURT OPCO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AVROHOM
Authorized Official - Middle Name:
Authorized Official - Last Name:TRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-730-4800
Mailing Address - Street 1:9526 W PICO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1202
Mailing Address - Country:US
Mailing Address - Phone:310-730-4800
Mailing Address - Fax:
Practice Address - Street 1:4545 SHELLEY CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-7232
Practice Address - Country:US
Practice Address - Phone:209-477-0271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility