1164495156 NPI number — STANLEY HEALTHCARE CENTER OPERATING COMPANY, LLC

Table of content: (NPI 1164495156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164495156 NPI number — STANLEY HEALTHCARE CENTER OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANLEY HEALTHCARE CENTER OPERATING COMPANY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STANLEY HEALTHCARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164495156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-796-2595
Provider Business Mailing Address Fax Number:
909-796-8797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14102 SPRINGDALE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92683-3538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-893-0026
Provider Business Practice Location Address Fax Number:
714-895-7298
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILIAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
909-796-2595

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  060000174 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060000174 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LTC55651F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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