Basic Information
Provider Information | |||||||||
NPI: | 1154320463 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROSEVILLE CARE CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ROSEVILLE CONVALESCENT HOSPITAL INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4020 SIERRA COLLEGE BLVD | ||||||||
Address2: | SUITE 190 | ||||||||
City: | ROCKLIN | ||||||||
State: | CA | ||||||||
PostalCode: | 956773906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166246230 | ||||||||
FaxNumber: | 9166246249 | ||||||||
Practice Location | |||||||||
Address1: | 1161 CIRBY WAY | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956614421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167821238 | ||||||||
FaxNumber: | 9167821238 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 06/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEAR | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9166246230 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HORIZON WEST HEALTHCARE, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 030000002 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | ZZR05886G | 05 | CA |   | MEDICAID |