Basic Information
| Provider Information | |||||||||
| NPI: | 1831573856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUCUMBER HOLDINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STONEY POINT HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E SAN MARCOS BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920692986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604710388 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21820 CRAGGY VIEW ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913112909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188828233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 08/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | TILFORD | ||||||||
| AuthorizedOfficialFirstName: | TOBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 76047100388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 920000019 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1831573856 | 05 | CA | MEDICAID |