Basic Information
| Provider Information | |||||||||
| NPI: | 1205932126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GORDON LANE HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GORDON LANE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 SATURN ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928216221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145773880 | ||||||||
| FaxNumber: | 7145773892 | ||||||||
| Practice Location | |||||||||
| Address1: | 1821 E CHAPMAN AVE | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928314102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148797301 | ||||||||
| FaxNumber: | 7142243320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AR MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7145773880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 060000118 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC55797F | 05 | CA | MEDICAID |