Provider Demographics
NPI:1649041195
Name:1338 20TH STREET LLC
Entity type:Organization
Organization Name:1338 20TH STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EZEQUIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-948-0193
Mailing Address - Street 1:12642 HATTERAS ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1525
Mailing Address - Country:US
Mailing Address - Phone:213-948-0193
Mailing Address - Fax:
Practice Address - Street 1:1338 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2034
Practice Address - Country:US
Practice Address - Phone:310-255-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility