Provider Demographics
NPI:1447656566
Name:PACIFIC VILLA, INC.
Entity type:Organization
Organization Name:PACIFIC VILLA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:626-331-0781
Mailing Address - Street 1:PO BOX 5004
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-0019
Mailing Address - Country:US
Mailing Address - Phone:626-331-0781
Mailing Address - Fax:626-966-7353
Practice Address - Street 1:3501 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3809
Practice Address - Country:US
Practice Address - Phone:626-331-0781
Practice Address - Fax:626-966-7353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-6313OtherPTAN
CA1447656566OtherNPI NUMBER
CA940000130Medicaid