Provider Demographics
NPI:1740698919
Name:PETALUMA HEALTHCARE & WELLNESS CENTRE, LP
Entity type:Organization
Organization Name:PETALUMA HEALTHCARE & WELLNESS CENTRE, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHLOMO
Authorized Official - Middle Name:
Authorized Official - Last Name:RECHNITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-634-1940
Mailing Address - Street 1:5900 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5013
Mailing Address - Country:US
Mailing Address - Phone:323-330-6500
Mailing Address - Fax:866-603-3566
Practice Address - Street 1:523 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4011
Practice Address - Country:US
Practice Address - Phone:707-763-2457
Practice Address - Fax:707-763-4860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC5570FMedicaid
CALTC5570FMedicaid