Provider Demographics
NPI:1720073059
Name:CHEVIOT GARDEN LP
Entity Type:Organization
Organization Name:CHEVIOT GARDEN LP
Other - Org Name:COUNTRY VILLA CHEVIOT GARDEN HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF CVHS, MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:REISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:5120 W GOLDLEAF CIR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1292
Mailing Address - Country:US
Mailing Address - Phone:310-574-3733
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:3533 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-4806
Practice Address - Country:US
Practice Address - Phone:310-836-8900
Practice Address - Fax:310-815-9786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA910000090314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06273KMedicaid
CA056451Medicare ID - Type Unspecified
CAZZT06273KMedicaid