Provider Demographics
NPI:1922083435
Name:HACIENDA C H INC
Entity Type:Organization
Organization Name:HACIENDA C H INC
Other - Org Name:BROADWAY BY THE SEA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-373-8373
Mailing Address - Street 1:25910 ACERO STE 350
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7908
Mailing Address - Country:US
Mailing Address - Phone:949-441-9258
Mailing Address - Fax:
Practice Address - Street 1:2725 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-5431
Practice Address - Country:US
Practice Address - Phone:562-434-4494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000084314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05894IMedicaid
CAZZT05894IMedicaid
CA1283240001Medicare NSC