Basic Information
| Provider Information | |||||||||
| NPI: | 1699837229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERRYMAN HEALTH, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALDSBURG SENIOR LIVING COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 E 400 S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841112846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013250153 | ||||||||
| FaxNumber: | 8015969001 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954484756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074334877 | ||||||||
| FaxNumber: | 7074335974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 12/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | LINCLON | ||||||||
| AuthorizedOfficialFirstName: | FAYE | ||||||||
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| AuthorizedOfficialTitleorPosition: | V.P. POLICY AND GOVERNMENT RELATION | ||||||||
| AuthorizedOfficialTelephone: | 8013250153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 010000014 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC55820F | 05 | CA | MEDICAID |