Provider Demographics
NPI:1528532454
Name:PACIFIC PARK HEALTHCARE CENTER LLC
Entity type:Organization
Organization Name:PACIFIC PARK HEALTHCARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLORZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-346-0300
Mailing Address - Street 1:107 W LEMON AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2809
Mailing Address - Country:US
Mailing Address - Phone:626-346-0300
Mailing Address - Fax:
Practice Address - Street 1:525 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2006
Practice Address - Country:US
Practice Address - Phone:626-658-7344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFIC HEALTHCARE GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06190FMedicaid