Provider Demographics
NPI:1811984065
Name:GREENFIELD COUNTRY CLUB
Entity type:Organization
Organization Name:GREENFIELD COUNTRY CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENQ
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-889-9929
Mailing Address - Street 1:1937 PONTIUS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:369 E PINE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2849
Practice Address - Country:US
Practice Address - Phone:760-873-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility