Basic Information
| Provider Information | |||||||||
| NPI: | 1154404010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN COMMUNITIES HEALTHCARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRINITY HOSPITAL SKILLED NURSING FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1229 | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960931229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306235541 | ||||||||
| FaxNumber: | 5306233920 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 EASTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960931229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306235541 | ||||||||
| FaxNumber: | 5306233920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5306232687 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 230000038 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC05923H | 05 | CA | MEDICAID |