Provider Demographics
NPI:1154683654
Name:WHEATFIELDS SENIOR LIVING
Entity Type:Organization
Organization Name:WHEATFIELDS SENIOR LIVING
Other - Org Name:CLOVIS SENIOR LIVING, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-737-8906
Mailing Address - Street 1:1701 SOUTH SUTRO TERRACE
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706
Mailing Address - Country:US
Mailing Address - Phone:775-468-6114
Mailing Address - Fax:775-562-4757
Practice Address - Street 1:4701 N. PRINCE STREET
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-762-8700
Practice Address - Fax:575-762-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT1 2191310400000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46427261Medicaid