Provider Demographics
NPI:1568456739
Name:COUNTRY VILLA EAST, L.P.
Entity Type:Organization
Organization Name:COUNTRY VILLA EAST, L.P.
Other - Org Name:COUNTRY VILLA PAVILION HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER OF GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:REISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:3580 WILSHIRE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2502
Mailing Address - Country:US
Mailing Address - Phone:323-330-6500
Mailing Address - Fax:
Practice Address - Street 1:5916 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2695
Practice Address - Country:US
Practice Address - Phone:323-939-3184
Practice Address - Fax:323-939-1966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA910000145314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05160GMedicaid
CAZZT05160GMedicaid