Provider Demographics
NPI:1265823264
Name:FALLBROOK HEALTHCARE CENTER OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:FALLBROOK HEALTHCARE CENTER OPERATING COMPANY, LLC
Other - Org Name:FALLBROOK SKILLED NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:KILIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-796-2595
Mailing Address - Street 1:PO BOX 3000
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-9000
Mailing Address - Country:US
Mailing Address - Phone:909-796-2595
Mailing Address - Fax:909-796-8797
Practice Address - Street 1:325 POTTER ST
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3068
Practice Address - Country:US
Practice Address - Phone:760-728-2330
Practice Address - Fax:760-728-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05298IMedicaid
CA550003129OtherSTATE LICENSE NUMBER
CAZZT05298IMedicaid