Provider Demographics
NPI:1063409472
Name:BAY CREST CARE CENTER, LLC
Entity type:Organization
Organization Name:BAY CREST CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:3750 GARNET STREET
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-3305
Mailing Address - Country:US
Mailing Address - Phone:310-371-2431
Mailing Address - Fax:310-214-4944
Practice Address - Street 1:3750 GARNET STREET
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-3305
Practice Address - Country:US
Practice Address - Phone:310-371-2431
Practice Address - Fax:310-214-4944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-30
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA910000008314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05559JMedicaid
CA055559Medicare Oscar/Certification