Provider Demographics
NPI:1831125608
Name:SAN GABRIEL MEDICAL INVESTORS, LLC
Entity Type:Organization
Organization Name:SAN GABRIEL MEDICAL INVESTORS, LLC
Other - Org Name:LIFE CARE CENTER OF SAN GABRIEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EUNICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-289-5365
Mailing Address - Street 1:909 W SANTA ANITA ST
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1018
Mailing Address - Country:US
Mailing Address - Phone:626-289-5365
Mailing Address - Fax:626-289-9503
Practice Address - Street 1:909 W SANTA ANITA ST
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1018
Practice Address - Country:US
Practice Address - Phone:626-289-5365
Practice Address - Fax:626-289-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
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
CAZZT05105NMedicaid
055105Medicare ID - Type Unspecified