1013937804 NPI number — PACIFIC COAST CARE CENTER, LLC

Table of content: (NPI 1013937804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013937804 NPI number — PACIFIC COAST CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC COAST CARE CENTER, 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:
KINDRED NURSING AND TRANSITIONAL CARE-PACIFIC COAST
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:
1013937804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
680 S. 4TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-596-7301
Provider Business Mailing Address Fax Number:
502-596-4134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 E ROMIE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93901-4208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-424-8072
Provider Business Practice Location Address Fax Number:
831-424-6329
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEAVER
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
502-596-7563

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  070000130 , 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: ZZR55090H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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