Provider Demographics
NPI:1649262957
Name:FOUNTAIN GARDENS CONVALESCENT HOSPITAL
Entity type:Organization
Organization Name:FOUNTAIN GARDENS CONVALESCENT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-761-7365
Mailing Address - Street 1:2222 SO SANTA ANA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059
Mailing Address - Country:US
Mailing Address - Phone:323-564-4461
Mailing Address - Fax:323-569-9565
Practice Address - Street 1:2222 SO SANTA ANA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:323-564-4461
Practice Address - Fax:323-569-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18416GMedicaid
CAZZT18416GMedicaid