Provider Demographics
NPI:1326037847
Name:ALTA CARE CENTER, LLC
Entity Type:Organization
Organization Name:ALTA CARE CENTER, LLC
Other - Org Name:ALTA GARDENS CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:13075 BLACKBIRD STREET
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-2902
Mailing Address - Country:US
Mailing Address - Phone:714-530-6322
Mailing Address - Fax:714-530-0284
Practice Address - Street 1:13075 BLACKBIRD STREET
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2902
Practice Address - Country:US
Practice Address - Phone:714-530-6322
Practice Address - Fax:714-530-0284
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-18
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000648314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55473GMedicaid
CA555473Medicare Oscar/Certification