Country Villa South Bay, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

COUNTRY VILLA SOUTH BAY, LLC

Practice address

13524 Sherman Way
Van Nuys, CA 91405-2830

Phone

(818) 786-3470

Fax

(818) 786-0943

NPI assigned

Sep 6, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Stephen E. Reissman

Title

Trustee of Managing Member

Phone

(310) 574-3733

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Country Villa Woodman Healthcare Center Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1104810159",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5120 W GOLDLEAF CIR",
            "address_2": "SUITE 400",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900561292",
            "telephone_number": "310-574-3733",
            "fax_number": "310-574-1322"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13524 SHERMAN WAY",
            "city": "VAN NUYS",
            "state": "CA",
            "postal_code": "914052830",
            "telephone_number": "818-786-3470",
            "fax_number": "818-786-0943"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY VILLA SOUTH BAY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-06",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "REISSMAN",
        "authorized_official_first_name": "STEPHEN",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "TRUSTEE OF MANAGING MEMBER",
        "authorized_official_telephone_number": "310-574-3733",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "CA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZT05712J",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Country Villa Woodman Healthcare Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• County of Los Angeles
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• Skilled Nursing Facility in Van Nuys, CA
• Providers in Van Nuys, CA by specialty
• Skilled Nursing Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.