Provider Demographics
NPI:1194120030
Name:BLYTHE POST ACUTE LLC
Entity type:Organization
Organization Name:BLYTHE POST ACUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-309-0022
Mailing Address - Street 1:530 N PUENTE ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-2804
Mailing Address - Country:US
Mailing Address - Phone:888-309-0022
Mailing Address - Fax:714-256-2003
Practice Address - Street 1:285 W CHANSLOR WAY
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1246
Practice Address - Country:US
Practice Address - Phone:760-922-8176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2016-12-30
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
CALTC90055IMedicaid
CA555383Medicare Oscar/Certification