1255622817 NPI number — WINDSOR CARE CENTER OF PETALUMA LLC

Table of content: (NPI 1255622817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255622817 NPI number — WINDSOR CARE CENTER OF PETALUMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINDSOR CARE CENTER OF PETALUMA 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:
Provider Other Organization Name Type Code:
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:
1255622817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9200 W SUNSET BLVD
Provider Second Line Business Mailing Address:
SUITE 700
Provider Business Mailing Address City Name:
WEST HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90069-3502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-385-1090
Provider Business Mailing Address Fax Number:
310-595-3752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 HAYES LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94952-4011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-763-2457
Provider Business Practice Location Address Fax Number:
707-347-4705
Provider Enumeration Date:
04/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CHAWLA
Authorized Official First Name:
ASH
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
310-385-1078

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  010000010 , 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)





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