Basic Information
| Provider Information | |||||||||
| NPI: | 1275923773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GUAVA HOLDINGS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | YUBA CITY POST-ACUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 E SAN MARCOS BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920692986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604710388 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 PLUMAS ST | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959913411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306710550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2015 | ||||||||
| LastUpdateDate: | 08/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TILFORD | ||||||||
| AuthorizedOfficialFirstName: | TOBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7604710388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 230000129 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1275923773 | 05 | CA | MEDICAID |