Provider Demographics
NPI:1619560216
Name:COMMUNITY CARE ON PALM RIVERSIDE, LLC
Entity Type:Organization
Organization Name:COMMUNITY CARE ON PALM RIVERSIDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EZRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-948-0193
Mailing Address - Street 1:1515 N FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1808
Mailing Address - Country:US
Mailing Address - Phone:951-686-9001
Mailing Address - Fax:951-367-0167
Practice Address - Street 1:4768 PALM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4012
Practice Address - Country:US
Practice Address - Phone:951-686-9001
Practice Address - Fax:951-367-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility