Provider Demographics
NPI:1083754253
Name:WALNUT HOUSE
Entity Type:Organization
Organization Name:WALNUT HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:M
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-483-6612
Mailing Address - Street 1:3401 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3241
Mailing Address - Country:US
Mailing Address - Phone:916-483-6612
Mailing Address - Fax:916-483-7134
Practice Address - Street 1:3401 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-3241
Practice Address - Country:US
Practice Address - Phone:916-483-6612
Practice Address - Fax:916-483-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARCF00023FMedicaid