Provider Demographics
NPI:1801126305
Name:COUNTRY VILLA EAST, LP
Entity type:Organization
Organization Name:COUNTRY VILLA EAST, LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT - CAMS
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:3580 WILSHIRE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2502
Mailing Address - Country:US
Mailing Address - Phone:323-330-6500
Mailing Address - Fax:
Practice Address - Street 1:6050 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2647
Practice Address - Country:US
Practice Address - Phone:323-653-5565
Practice Address - Fax:323-782-9516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801126305Medicaid