Provider Demographics
NPI:1205839081
Name:INDUSTRY CONVALESCENT HOSPITAL
Entity type:Organization
Organization Name:INDUSTRY CONVALESCENT HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-336-1274
Mailing Address - Street 1:555 S. EL ENCANTO ROAD
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91745
Mailing Address - Country:US
Mailing Address - Phone:626-336-1274
Mailing Address - Fax:626-330-2789
Practice Address - Street 1:555 S. EL ENCANTO RD
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91745
Practice Address - Country:US
Practice Address - Phone:626-336-1274
Practice Address - Fax:626-330-2789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000747314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18646GMedicaid
CA555395Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER