Provider Demographics
NPI:1790001212
Name:DRIFTWOOD HEALTHCARE & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:DRIFTWOOD HEALTHCARE & WELLNESS CENTER, LLC
Other - Org Name:DRIFTWOOD HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:3223-855-5492
Mailing Address - Street 1:4109 EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-3105
Mailing Address - Country:US
Mailing Address - Phone:310-371-4628
Mailing Address - Fax:310-214-1882
Practice Address - Street 1:4109 EMERALD ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-3105
Practice Address - Country:US
Practice Address - Phone:310-371-4628
Practice Address - Fax:310-214-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA910000045314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06034HMedicaid
CA555114Medicare Oscar/Certification