Basic Information
| Provider Information | |||||||||
| NPI: | 1255656930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRIDLEY HEALTHCARE & WELLNESS CENTRE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | GRIDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959482216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308466266 | ||||||||
| FaxNumber: | 5308460331 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | GRIDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959482216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308466266 | ||||||||
| FaxNumber: | 5308460331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2010 | ||||||||
| LastUpdateDate: | 04/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3236341940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 230000047 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZR18521H | 05 | CA | MEDICAID |