| Contacts | Authorizing Official | Update | Change Request | Limbaga, Aries
Chief Executive Officer
Rancho Los Amigos National Rehabilitation Center
5623857022 | Wilks, Konita
CEO
Rancho Los Amigos National Rehabilitation Center
5623857022 | 11/12/2024 11:13 AM |
| Addresses | Main Address | Update | Recertification |
7601 EAST IMPERIAL HIGHWAY
DOWNEY, CA 90242 |
7601 IMPERIAL HIGHWAY
DOWNEY, CA 90242 | 8/13/2024 1:05 PM |
| Addresses | Shipping Address | Delete | Recertification | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 EAST IMPERIAL HIGHWAY
JPI BLDG RM B007
DOWNEY, CA 90242 | | 8/13/2024 1:05 PM |
| Addresses | Shipping Address | Insert | Recertification | | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 IMPERIAL HIGHWAY
JPI BLDG RM B007
DOWNEY, CA 90242 | 8/13/2024 1:05 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 8/13/2024 1:05 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | HSC32014W | 8/13/2024 1:05 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | CA | 8/13/2024 1:05 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1275540171 | 8/13/2024 1:05 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 8/13/2024 1:05 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2023 8:05:08 AM | 8/13/2024 1:05:03 PM | 8/13/2024 1:05 PM |
| Addresses | Shipping Address | Insert | Change Request | | DHS LA County Central Fill (Rx E-Fill Solutions)
27680 AVENUE MENTRY
SUITE 100
VALENCIA, CA 91355 | 3/19/2024 8:11 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2022 11:22:27 AM | 8/16/2023 8:05:08 AM | 8/16/2023 8:05 AM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2021 1:20:50 PM | 8/24/2022 11:22:27 AM | 8/24/2022 11:22 AM |
| Addresses | Shipping Address | Update | Change Request | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 EAST IMPERIAL HIGHWAY
BLDG 100 - RM 019
DOWNEY, CA 90242 | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 EAST IMPERIAL HIGHWAY
JPI BLDG RM B007
DOWNEY, CA 90242 | 12/14/2021 1:46 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2020 9:47:46 AM | 8/19/2021 1:20:50 PM | 8/19/2021 1:20 PM |
| Addresses | Shipping Address | Insert | Change Request | | DHS LA County Central Fill (Rx E-Fill Solutions)
28341 CONSTELLATION RD
Santa Clarita, CA 91355 | 2/4/2021 4:09 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1144342932 | 9/7/2020 9:47 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/7/2020 9:47 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1639186539 | 9/7/2020 9:47 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/7/2020 9:47 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1144342932 ( ) | | 9/7/2020 9:47 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1639186539 ( ) | | 9/7/2020 9:47 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 10:55:22 AM | 9/7/2020 9:47:46 AM | 9/7/2020 9:47 AM |
| Contacts | Primary Contact | Update | Change Request | Kakehashi, Bryan Dean
Pharmacy Chief
Rancho Los Amigos National Rehabilitation Center
5623857395 | Phan, Justin Phuc
Pharmacist
Rancho Los Amigos National Rehabilitation Center
5623858430 | 1/23/2020 1:14 PM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2018 1:13:55 PM | 8/26/2019 10:55:22 AM | 8/26/2019 10:55 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/18/2018 5:09 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | FHC42014F | 10/18/2018 5:09 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | CA | 10/18/2018 5:09 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1639186539 | 10/18/2018 5:09 PM |
| Addresses | Main Address | Update | Change Request |
7601 EAST IMPERIAL HIGHWAY
BLDG 100 - RM 019
DOWNEY, CA 90242 |
7601 EAST IMPERIAL HIGHWAY
DOWNEY, CA 90242 | 10/17/2018 8:52 AM |
| Addresses | Shipping Address | Delete | Change Request | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 EAST IMPERIAL HIGHWAY
BLDG 100 - RM 123A
DOWNEY, CA 90242 | | 10/17/2018 8:52 AM |
| Addresses | Shipping Address | Insert | Change Request | | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 EAST IMPERIAL HIGHWAY
BLDG 100 - RM 019
DOWNEY, CA 90242 | 10/17/2018 8:52 AM |
| Addresses | Main Address | Update | Change Request |
7601 EAST IMPERIAL HIGHWAY
DOWNEY, CA 90242 |
7601 EAST IMPERIAL HIGHWAY
BLDG 100 - RM 019
DOWNEY, CA 90242 | 10/15/2018 3:39 PM |
| Addresses | Shipping Address | Insert | Change Request | | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER
7601 EAST IMPERIAL HIGHWAY
BLDG 100 - RM 123A
DOWNEY, CA 90242 | 10/15/2018 3:39 PM |
| Details | Last Recertification Date | Update | Recertification | 11/8/2017 12:12:44 PM | 8/29/2018 1:13:55 PM | 8/29/2018 1:13 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Limbaga, Aries
Interim Chief Executive Officer
Rancho Los Amigos National Rehabilitation Center
5623857022 | Limbaga, Aries
Chief Executive Officer
Rancho Los Amigos National Rehabilitation Center
5623857022 | 8/28/2018 6:45 PM |
| Contacts | Authorizing Official | Update | Change Request | OROZCO, JORGE
CEO
RLANRC
5623857022 | Limbaga, Aries
Interim Chief Executive Officer
Rancho Los Amigos National Rehabilitation Center
5623857022 | 5/11/2018 1:25 PM |
| Details | Last Recertification Date | Update | Recertification | 8/10/2016 12:00:00 AM | 11/8/2017 12:12:44 PM | 11/8/2017 12:12 PM |
| Contacts | Authorizing Official | Update | Change Request | Kakehashi, Bryan Dean
Pharmacy Chief
Rancho Los Amigos National Rehabilitation Center
5623857395 | OROZCO, JORGE
CEO
RLANRC
5623857022 | 10/18/2017 12:44 PM |
| Contacts | Primary Contact | Update | Change Request | JOYO, BRIAN
PHARMACY DIRECTOR
5624017239 | Kakehashi, Bryan Dean
Pharmacy Chief
Rancho Los Amigos National Rehabilitation Center
5623857395 | 10/18/2017 12:44 PM |
| Contacts | Authorizing Official | Update | AO Change Request | OROZCO, JORGE
CEO
5624017022 | Kakehashi, Bryan Dean
Pharmacy Chief
Rancho Los Amigos National Rehabilitation Center
5623857395 | 9/29/2017 10:45 AM |
| Addresses | Main Address | Insert | | |
7601 EAST IMPERIAL HIGHWAY
DOWNEY, CA 90242 | 9/7/2016 9:34 PM |
| Contacts | Authorizing Official | Insert | | | OROZCO, JORGE
CEO
5624017022 | 9/7/2016 9:34 PM |
| Contacts | Primary Contact | Insert | | | JOYO, BRIAN
PHARMACY DIRECTOR
5624017239 | 9/7/2016 9:34 PM |
| Details | Last Recertification Date | Update | | 8/12/2015 12:00:00 AM | 8/10/2016 12:00:00 AM | 8/31/2016 1:17 PM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 8/12/2015 12:08 PM |
| Details | Last Recertification Date | Update | | 8/7/2014 12:00:00 AM | 8/12/2015 12:00:00 AM | 8/12/2015 12:08 PM |
| Details | Last Recertification Date | Update | | 8/22/2013 12:00:00 AM | 8/7/2014 12:00:00 AM | 8/7/2014 7:53 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 8/22/2013 12:00:00 AM | 8/22/2013 12:59 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1144342932 | 5/15/2012 7:17 AM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/15/2012 7:17 AM |
| Details | Last Recertification Date | Insert | | | | 4/28/2008 12:10 PM |
| Details | Grant Number | Insert | | | | 4/28/2008 12:10 PM |
| Details | 340B ID | Insert | | | DSH050717 | 4/28/2008 12:10 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/28/2008 12:10 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/28/2008 12:10 PM |
| Details | Medicare Provider Number | Insert | | | 050717 | 4/28/2008 12:10 PM |
| Details | Entity Name | Insert | | | RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER | 4/28/2008 12:10 PM |
| Details | Program Code | Insert | | | DSH | 4/28/2008 12:10 PM |
| Details | Entity Subname | Insert | | | | 4/28/2008 12:10 PM |
| Dates | Participating Approval Date | Insert | | | 9/10/2007 12:00:00 AM | 4/28/2008 12:10 PM |
| Details | State | Insert | | | Active | 4/28/2008 12:10 PM |
| Dates | Registration Date | Insert | | | 9/10/2007 12:00:00 AM | 4/28/2008 12:10 PM |
| Dates | Signed By Date | Insert | | | | 4/28/2008 12:10 PM |
| Dates | Start Date | Insert | | | 1/1/2001 12:00:00 AM | 4/28/2008 12:10 PM |
| Terminations | Termination Comments | Insert | | | | 4/28/2008 12:10 PM |
| Terminations | Termination Date | Insert | | | | 4/28/2008 12:10 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/28/2008 12:10 PM |
| Terminations | Termination Reason | Insert | | | | 4/28/2008 12:10 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 9/10/2007 3:22 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | PHB142050 | 9/10/2007 3:22 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 9/10/2007 3:22 PM |