Basic Information
Provider Information | |||||||||
NPI: | 1992960363 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTRY OAKS PARTNERS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COUNTRY OAKS CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3050 SATURN ST | ||||||||
Address2: | STE 201 | ||||||||
City: | BREA | ||||||||
State: | CA | ||||||||
PostalCode: | 928216221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7145773880 | ||||||||
FaxNumber: | 7145773892 | ||||||||
Practice Location | |||||||||
Address1: | 215 W PEARL ST | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917683114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096221067 | ||||||||
FaxNumber: | 9096220412 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2008 | ||||||||
LastUpdateDate: | 12/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NELSON | ||||||||
AuthorizedOfficialFirstName: | JEANNE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AR MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7145773880 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 950000086 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.