1235275975 NPI number — WINDSOR ELK GROVE CARE AND REHABILITATION, LLC

Table of content: (NPI 1235275975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235275975 NPI number — WINDSOR ELK GROVE CARE AND REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINDSOR ELK GROVE CARE AND REHABILITATION, 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:
WINDSOR ELK GROVE CARE AND REHABILITATION 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:
1235275975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9461 BATEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95624-2005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-685-9525
Provider Business Mailing Address Fax Number:
916-685-3373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9200 W SUNSET BLVD
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
WEST HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90069-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-385-1090
Provider Business Practice Location Address Fax Number:
310-595-3792
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHAWLA
Authorized Official First Name:
ASH
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, FINANCE
Authorized Official Telephone Number:
310-385-1090

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  100000001 , 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: ZZR05308I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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