Provider Demographics
NPI:1912248972
Name:BRIGHTON CONVALESCENT, LLC
Entity Type:Organization
Organization Name:BRIGHTON CONVALESCENT, LLC
Other - Org Name:BRIGHTON CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CIPRIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-512-2595
Mailing Address - Street 1:1836 N FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1619
Mailing Address - Country:US
Mailing Address - Phone:626-798-9124
Mailing Address - Fax:626-794-2964
Practice Address - Street 1:1836 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1619
Practice Address - Country:US
Practice Address - Phone:626-512-2595
Practice Address - Fax:626-794-2964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000194314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912248972Medicaid
CA1912248972Medicaid