Provider Demographics
NPI:1194877324
Name:CALIFORNIA CONVALESCENT CENTER 1 INC
Entity type:Organization
Organization Name:CALIFORNIA CONVALESCENT CENTER 1 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-682-7027
Mailing Address - Street 1:909 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2113
Mailing Address - Country:US
Mailing Address - Phone:213-385-7301
Mailing Address - Fax:213-385-0539
Practice Address - Street 1:909 S LAKE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2113
Practice Address - Country:US
Practice Address - Phone:213-385-7301
Practice Address - Fax:213-385-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000065314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05461JMedicaid
CAZZT05461JMedicaid
055461Medicare Oscar/Certification