Provider Demographics
NPI:1457345001
Name:AG LA MESA, LLC
Entity Type:Organization
Organization Name:AG LA MESA, LLC
Other - Org Name:COUNTRY MANOR LA MESA HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-651-1808
Mailing Address - Street 1:5696 LAKE MURRAY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-460-7871
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:5696 LAKE MURRAY BOULEVARD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-460-7871
Practice Address - Fax:619-460-4810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05910JMedicaid
CA055910Medicare Oscar/Certification
CAZZT05910JMedicaid