Provider Demographics
NPI:1821096066
Name:MARY HEALTH OF THE SICK CONVALESCENT AND NURSING HOSPITAL INCORPORATED
Entity Type:Organization
Organization Name:MARY HEALTH OF THE SICK CONVALESCENT AND NURSING HOSPITAL INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-498-3644
Mailing Address - Street 1:2929 THERESA DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3136
Mailing Address - Country:US
Mailing Address - Phone:805-498-3644
Mailing Address - Fax:805-498-5112
Practice Address - Street 1:2929 THERESA DR
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-3136
Practice Address - Country:US
Practice Address - Phone:805-498-3644
Practice Address - Fax:805-498-5112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05022FMedicaid
CAZZT05022FMedicaid