Provider Demographics
NPI:1770884868
Name:9025 COLORADO AVENUE LLC
Entity type:Organization
Organization Name:9025 COLORADO AVENUE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:MORITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-363-3170
Mailing Address - Street 1:9025 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-2157
Mailing Address - Country:US
Mailing Address - Phone:951-688-3636
Mailing Address - Fax:
Practice Address - Street 1:9025 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-2157
Practice Address - Country:US
Practice Address - Phone:951-688-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770884868Medicare PIN
CA056315Medicare Oscar/Certification