Provider Demographics
NPI:1639548449
Name:AGVA, LLC
Entity Type:Organization
Organization Name:AGVA, LLC
Other - Org Name:KEI-AI SOUTH BAY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-347-7100
Mailing Address - Street 1:15115 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4101
Mailing Address - Country:US
Mailing Address - Phone:310-532-0700
Mailing Address - Fax:310-532-0001
Practice Address - Street 1:15115 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4101
Practice Address - Country:US
Practice Address - Phone:310-532-0700
Practice Address - Fax:310-532-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555306Medicare Oscar/Certification