Provider Demographics
NPI:1699780064
Name:SOUTH PASADENA REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:SOUTH PASADENA REHABILITATION CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:
Authorized Official - Last Name:REGGEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-799-9571
Mailing Address - Street 1:904 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3144
Mailing Address - Country:US
Mailing Address - Phone:626-799-9571
Mailing Address - Fax:626-799-2734
Practice Address - Street 1:904 MISSION ST
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3144
Practice Address - Country:US
Practice Address - Phone:626-799-9571
Practice Address - Fax:626-799-2734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000038314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05931GMedicaid
CA055931Medicare Oscar/Certification
CAZZT05931GMedicaid