Provider Demographics
NPI:1255334587
Name:WDW JOINT VENTURE
Entity type:Organization
Organization Name:WDW JOINT VENTURE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:COBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-862-6506
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:8425 IOWA STREET
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-0340
Mailing Address - Country:US
Mailing Address - Phone:562-862-6506
Mailing Address - Fax:562-869-1346
Practice Address - Street 1:8425 IOWA ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4929
Practice Address - Country:US
Practice Address - Phone:562-862-6506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000223313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55128FMedicaid
CALTC55128FMedicaid