Provider Demographics
NPI:1184055956
Name:SRSW LLC
Entity type:Organization
Organization Name:SRSW LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SAMUELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-445-1000
Mailing Address - Street 1:4 S STONINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-6741
Mailing Address - Country:US
Mailing Address - Phone:949-445-1000
Mailing Address - Fax:
Practice Address - Street 1:919 N SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-1244
Practice Address - Country:US
Practice Address - Phone:949-445-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SRSO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-04
Last Update Date:2017-05-30
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
CA2857712Medicaid
CA056331Medicare Oscar/Certification