Basic Information
| Provider Information | |||||||||
| NPI: | 1265823264 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FALLBROOK HEALTHCARE CENTER OPERATING COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FALLBROOK SKILLED NURSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3000 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923549000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097962595 | ||||||||
| FaxNumber: | 9097968797 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 POTTER ST | ||||||||
| Address2: | |||||||||
| City: | FALLBROOK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920283068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607282330 | ||||||||
| FaxNumber: | 7607285844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KILIAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | BARRY | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9097962595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05298I | 05 | CA | MEDICAID | 550003129 | 01 | CA | STATE LICENSE NUMBER | OTHER |