Provider Demographics
NPI:1316080260
Name:BROADWATER ONTARIO CARE CENTER, LLC
Entity type:Organization
Organization Name:BROADWATER ONTARIO CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-368-1862
Mailing Address - Street 1:1661 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-5826
Mailing Address - Country:US
Mailing Address - Phone:909-984-6713
Mailing Address - Fax:909-984-5254
Practice Address - Street 1:1661 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-5826
Practice Address - Country:US
Practice Address - Phone:909-984-6713
Practice Address - Fax:909-984-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000181314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316080260Medicaid
CA6091540001Medicare NSC
CA055707Medicare Oscar/Certification