Provider Demographics
NPI:1760470736
Name:ALEXANDRIA CARE CENTER LLC
Entity Type:Organization
Organization Name:ALEXANDRIA CARE CENTER LLC
Other - Org Name:ALEXANDRIA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:1515 N ALEXANDRIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5203
Mailing Address - Country:US
Mailing Address - Phone:323-660-1800
Mailing Address - Fax:323-660-0023
Practice Address - Street 1:1515 N ALEXANDRIA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5203
Practice Address - Country:US
Practice Address - Phone:323-660-1800
Practice Address - Fax:323-660-0023
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-12
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000002314000000X
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT180000FMedicaid
CAZZT180000FMedicaid