Provider Demographics
NPI:1629146097
Name:SEACREST CONVALESCENT HOSPITAL, INC.
Entity Type:Organization
Organization Name:SEACREST CONVALESCENT HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDOMAR
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:310-833-3526
Mailing Address - Street 1:1416 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3503
Mailing Address - Country:US
Mailing Address - Phone:310-833-3526
Mailing Address - Fax:310-832-3390
Practice Address - Street 1:1416 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3503
Practice Address - Country:US
Practice Address - Phone:310-833-3526
Practice Address - Fax:310-832-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05070FMedicaid
CA0623415Medicare UPIN
CA0300130001Medicare NSC
CA055070Medicare ID - Type Unspecified