Basic Information
| Provider Information | |||||||||
| NPI: | 1770689697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYNGATE NURSING CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH VALLEY NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 SATURN STREET | ||||||||
| Address2: | SUITE #201 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928216278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145773880 | ||||||||
| FaxNumber: | 7145773895 | ||||||||
| Practice Location | |||||||||
| Address1: | 7660 WYNGATE ST | ||||||||
| Address2: | |||||||||
| City: | TUJUNGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910421736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183521454 | ||||||||
| FaxNumber: | 8189514250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 01/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | MORTENSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7145773880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | ZZT05146K | 05 | CA | MEDICAID |