Provider Demographics
NPI:1710960885
Name:EQUICARE MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:EQUICARE MEDICAL SUPPLY, INC.
Other - Org Name:EMERALD TERRACE CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:BERNARDO
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:BNHA6137
Authorized Official - Phone:213-385-1715
Mailing Address - Street 1:1154 S ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-4110
Mailing Address - Country:US
Mailing Address - Phone:213-385-1715
Mailing Address - Fax:213-385-7802
Practice Address - Street 1:1154 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-4110
Practice Address - Country:US
Practice Address - Phone:213-385-1715
Practice Address - Fax:213-385-7802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EQUICARE MEDICAL SUPPLY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-22
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000064313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06157IMedicaid
CAZZT06157IMedicaid
056157Medicare Oscar/Certification