Basic Information
Provider Information | |||||||||
NPI: | 1427049816 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOODLAND CARE CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOODLAND CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7120 CORBIN AVE. | ||||||||
Address2: |   | ||||||||
City: | RESEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 913353618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188814540 | ||||||||
FaxNumber: | 8188810039 | ||||||||
Practice Location | |||||||||
Address1: | 7120 CORBIN AVE. | ||||||||
Address2: |   | ||||||||
City: | RESEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 913353618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188814540 | ||||||||
FaxNumber: | 8188810039 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2005 | ||||||||
LastUpdateDate: | 02/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERG | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 5054684752 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUMMIT CARE LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 920000024 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | ZZT06066I | 05 | CA |   | MEDICAID |