Provider Demographics
NPI:1730269234
Name:CASA BONITA CONVALESCENT HOSPITAL LLC
Entity type:Organization
Organization Name:CASA BONITA CONVALESCENT HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-389-6900
Mailing Address - Street 1:4032 WILSHIRE BLVD FL 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3425
Mailing Address - Country:US
Mailing Address - Phone:213-389-6900
Mailing Address - Fax:909-599-7178
Practice Address - Street 1:535 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3124
Practice Address - Country:US
Practice Address - Phone:909-599-1248
Practice Address - Fax:909-599-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC70110GMedicaid
CALTC06291JMedicaid
CALTC70110GMedicaid