Provider Demographics
NPI:1922095215
Name:COORDINATED CARE CENTER, INC
Entity Type:Organization
Organization Name:COORDINATED CARE CENTER, INC
Other - Org Name:SAN MARINO MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-446-5263
Mailing Address - Street 1:6812 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-2030
Mailing Address - Country:US
Mailing Address - Phone:626-446-5263
Mailing Address - Fax:626-446-8109
Practice Address - Street 1:6812 OAK AVE
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91775-2030
Practice Address - Country:US
Practice Address - Phone:626-446-5263
Practice Address - Fax:626-446-8109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
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
CAZZT18606FMedicaid
CAZZT18606FMedicaid