Provider Demographics
NPI:1851388458
Name:COMMUNITY CONVALESCENT CENTER OF MONTCLAIR INC
Entity Type:Organization
Organization Name:COMMUNITY CONVALESCENT CENTER OF MONTCLAIR INC
Other - Org Name:COMMUNITY EXTENDED CARE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:PIACENTI
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-930-0777
Mailing Address - Street 1:4115 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-1532
Mailing Address - Country:US
Mailing Address - Phone:562-930-0777
Mailing Address - Fax:562-930-0728
Practice Address - Street 1:9620 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2320
Practice Address - Country:US
Practice Address - Phone:909-621-4751
Practice Address - Fax:909-621-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000243314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC06444FMedicaid
CALTC70142FMedicaid
CA0533700001Medicare NSC
CALTC70142FMedicaid