Provider Demographics
NPI:1144613142
Name:CROSS CREEK CARE, INC
Entity Type:Organization
Organization Name:CROSS CREEK CARE, INC
Other - Org Name:CROSS CREEK COTTAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WINFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:949-722-1014
Mailing Address - Street 1:138 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3035
Mailing Address - Country:US
Mailing Address - Phone:949-722-1014
Mailing Address - Fax:949-631-5205
Practice Address - Street 1:138 E 18TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3035
Practice Address - Country:US
Practice Address - Phone:949-722-1014
Practice Address - Fax:949-631-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-15
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306000888310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility