Provider Demographics
NPI:1194767871
Name:FOUNTAIN VIEW SUBACUTE & NURSING CENTER, LLC
Entity type:Organization
Organization Name:FOUNTAIN VIEW SUBACUTE & NURSING 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 1:5310 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1005
Mailing Address - Country:US
Mailing Address - Phone:323-461-9961
Mailing Address - Fax:323-461-6854
Practice Address - Street 1:5310 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1005
Practice Address - Country:US
Practice Address - Phone:323-461-9961
Practice Address - Fax:323-461-6854
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-10
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000008314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC70087FMedicaid
CAZZT05111FMedicaid
CAZZT05111FMedicaid