Provider Demographics
NPI:1619121092
Name:BLYTHE/WINDSOR COUNTRY PARK HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:BLYTHE/WINDSOR COUNTRY PARK HEALTHCARE CENTER, LLC
Other - Org Name:WINDSOR GARDENS CONVALESCENT CENTER OF LONG BEACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ASH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAWLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-385-1090
Mailing Address - Street 1:3232 E ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2811
Mailing Address - Country:US
Mailing Address - Phone:562-422-9219
Mailing Address - Fax:562-428-0280
Practice Address - Street 1:3232 E ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-2811
Practice Address - Country:US
Practice Address - Phone:562-422-9219
Practice Address - Fax:562-428-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000067314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555375Medicare Oscar/Certification