- Enrollment id
- O20091029000529
- Enrollment state
- CA
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1194898205
- Multiple npi flag
- N
- Ccn
- 555088
- Associate id
- 2769567452
- Organization name
- MID-WILSHIRE HEALTH CARE CENTER
- Doing business as name
- FIDELITY HEALTH CARE & REHAB
- Incorporation date
- 2001-03-16
- Incorporation state
- CA
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Nursing home provider name
- FIDELITY HEALTH CARE
- Affiliation entity name
- IL & JOAN LEE
- Affiliation entity id
- 741
- Address line 1
- 11210 LOWER AZUSA RD
- City
- EL MONTE
- State
- CA
- Zip code
- 917311412