Basic Information
| Provider Information | |||||||||
| NPI: | 1598089351 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRIDLEY HEALTHCARE & WELLNESS CENTRE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRIDLEY HEALTHCARE & WELLNESS CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | GRIDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959482216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308466266 | ||||||||
| FaxNumber: | 5308460668 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | GRIDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959482216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308466266 | ||||||||
| FaxNumber: | 5308460668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | PETTERSON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - CAMS | ||||||||
| AuthorizedOfficialTelephone: | 3105743733 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 555124 | 01 | CA | MEDICARE | OTHER |