Provider Demographics
NPI:1982693073
Name:ST. JOHN OF GOD RETIREMENT AND CARE CENTER
Entity Type:Organization
Organization Name:ST. JOHN OF GOD RETIREMENT AND CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-731-0641
Mailing Address - Street 1:2468 S ST ANDREWS PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-2042
Mailing Address - Country:US
Mailing Address - Phone:323-731-0641
Mailing Address - Fax:323-737-1452
Practice Address - Street 1:2468 S ST ANDREWS PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-2042
Practice Address - Country:US
Practice Address - Phone:323-731-0641
Practice Address - Fax:323-737-1452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000022314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05253FMedicaid
CA05-5253Medicare ID - Type UnspecifiedMEDICARE PROVIDER
CA0841090001Medicare NSC