# COUNTRY VILLA SOUTH BAY, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Country Villa Woodman Healthcare Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104810159
- **Authorized official:** MR. STEPHEN E. REISSMAN (TRUSTEE OF MANAGING MEMBER)
- **Authorized official phone:** (310) 574-3733

## Contact information

- **Practice address:** 13524 SHERMAN WAY, VAN NUYS, CA 91405-2830
- **Practice address phone:** (818) 786-3470
- **Practice address fax:** (818) 786-0943
- **Mailing address:** 5120 W GOLDLEAF CIR, SUITE 400, LOS ANGELES, CA 90056-1292
- **Mailing address phone:** (310) 574-3733
- **Mailing address fax:** (310) 574-1322

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | — | CA | Yes |

## Other

- **Enumeration date:** 09/06/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | ZZT05712J | — | CA |