Provider Demographics
NPI:1114636230
Name:EAGLE LAKE VILLAGE
Entity Type:Organization
Organization Name:EAGLE LAKE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CIMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-704-6275
Mailing Address - Street 1:2001 PAUL BUNYAN RD.
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130
Mailing Address - Country:US
Mailing Address - Phone:530-457-4380
Mailing Address - Fax:
Practice Address - Street 1:2001 PAUL BUNYAN RD.
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130
Practice Address - Country:US
Practice Address - Phone:530-457-4380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility