Basic Information
| Provider Information | |||||||||
| NPI: | 1548269855 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEPORT SKILLED NURSING CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4020 SIERRA COLLEGE BLVD | ||||||||
| Address2: | SUITE #190 | ||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956773906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166246230 | ||||||||
| FaxNumber: | 9166246249 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 16TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954533599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072636300 | ||||||||
| FaxNumber: | 7072636300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | BEAR | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9166246230 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HORIZON WEST HEALTHCARE OF CALIFORNIA, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 110000509 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZR05499G | 05 | CA | MEDICAID |