Basic Information
| Provider Information | |||||||||
| NPI: | 1659374981 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CABRILLO CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 AUGUSTA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934015820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055445100 | ||||||||
| FaxNumber: | 8055447209 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 AUGUSTA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934015820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055445100 | ||||||||
| FaxNumber: | 8055447209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROLDAN | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8055445100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | ZZT06189H | 05 | CA | MEDICAID |