Provider Demographics
NPI:1730483058
Name:TAG-2 MEDICAL INVESTMENT GROUP LLC
Entity Type:Organization
Organization Name:TAG-2 MEDICAL INVESTMENT GROUP LLC
Other - Org Name:SUNNY VILLAGE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:SIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-943-6298
Mailing Address - Street 1:1668 S GARFIELD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-5400
Mailing Address - Country:US
Mailing Address - Phone:626-943-6298
Mailing Address - Fax:
Practice Address - Street 1:1516 S MARENGO AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3055
Practice Address - Country:US
Practice Address - Phone:626-576-1032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA055203Medicare Oscar/Certification