Basic Information
| Provider Information | |||||||||
| NPI: | 1811963028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDSOR HEALTHCARE GOLDEN PALMS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN HILL SUBACUTE AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 34TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921022416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192322946 | ||||||||
| FaxNumber: | 6192324665 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 34TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921022416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192322946 | ||||||||
| FaxNumber: | 6192324665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | FIEGEN | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3103851090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 090000052 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT06182K | 05 | CA | MEDICAID |