Provider Demographics
NPI:1073503074
Name:ENTER CARE MACLAY SWC
Entity type:Organization
Organization Name:ENTER CARE MACLAY SWC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DONOHOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-361-4455
Mailing Address - Street 1:12831 MACLAY ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4934
Mailing Address - Country:US
Mailing Address - Phone:818-361-4455
Mailing Address - Fax:818-837-9369
Practice Address - Street 1:12831 MACLAY ST
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4934
Practice Address - Country:US
Practice Address - Phone:818-361-4455
Practice Address - Fax:818-837-9369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55583GMedicaid
CALTC55583GMedicaid