Provider Demographics
NPI:1972719037
Name:PACIFIC PALMS HEALTHCARE, LLC
Entity type:Organization
Organization Name:PACIFIC PALMS HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GOVERNING BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-320-6319
Mailing Address - Street 1:1020 TERMINO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4123
Mailing Address - Country:US
Mailing Address - Phone:562-433-6791
Mailing Address - Fax:562-433-9801
Practice Address - Street 1:1020 TERMINO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4123
Practice Address - Country:US
Practice Address - Phone:562-433-6791
Practice Address - Fax:562-433-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06164GMedicaid
CAZZT06164GMedicaid