Provider Demographics
NPI:1265453914
Name:CHANCELLOR HEALTH CARE OF CALIFORNIA I INC
Entity Type:Organization
Organization Name:CHANCELLOR HEALTH CARE OF CALIFORNIA I INC
Other - Org Name:LINDA VALLEY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CORBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-796-0235
Mailing Address - Street 1:25383 COLE ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3103
Mailing Address - Country:US
Mailing Address - Phone:909-796-0235
Mailing Address - Fax:909-796-4945
Practice Address - Street 1:25383 COLE ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3103
Practice Address - Country:US
Practice Address - Phone:909-796-0235
Practice Address - Fax:909-796-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000167314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA055299Medicare ID - Type Unspecified