Provider Demographics
NPI:1215930995
Name:EISENBERG VILLAGE OF THE LOS ANGELES JEWISH HOME FOR THE AGING
Entity type:Organization
Organization Name:EISENBERG VILLAGE OF THE LOS ANGELES JEWISH HOME FOR THE AGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-774-9208
Mailing Address - Street 1:18855 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6445
Mailing Address - Country:US
Mailing Address - Phone:818-774-3000
Mailing Address - Fax:
Practice Address - Street 1:18855 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6445
Practice Address - Country:US
Practice Address - Phone:818-774-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA920000043313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT08013FMedicaid
CAZZT08013FMedicaid
CA0580850001Medicare NSC