Organization
DEL ROSA VILLA, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELIZABETH PLOTT TYLER J.D (VICE PRESIDENT OF OPERATIONS)
(323) 655-6960
Entity
Organization
Contact information
Practice address
2018 DEL ROSA AVE, SAN BERNARDINO, CA 92404-5642
(909) 885-3261
(909) 888-3871
Mailing address
5455 WILSHIRE BLVD, SUITE 1925, LOS ANGELES, CA 90036-4201
(323) 655-6960
(323) 655-7122
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
240000029
CA
314000000X
Skilled Nursing Facility
Primary
240000029
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
55-5195
MEDICARE ID-TYPE UNSPECIFIED
CA
05
—
LTC90017G
—
CA
Enumeration date
08/03/2005
Last updated
03/05/2015
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