Provider Demographics
NPI:1336212455
Name:MID-WILSHIRE HEALTH CARE CENTER, INC
Entity Type:Organization
Organization Name:MID-WILSHIRE HEALTH CARE CENTER, INC
Other - Org Name:TUSTIN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JEOUNG
Authorized Official - Middle Name:HIE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-934-5660
Mailing Address - Street 1:1101 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3112
Mailing Address - Country:US
Mailing Address - Phone:323-934-5660
Mailing Address - Fax:323-934-0852
Practice Address - Street 1:1051 BRYAN AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4419
Practice Address - Country:US
Practice Address - Phone:714-832-6780
Practice Address - Fax:714-832-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT11108HMedicaid