Provider Demographics
NPI:1407123417
Name:WILDCREEK HEALTHCARE, INC.
Entity Type:Organization
Organization Name:WILDCREEK HEALTHCARE, INC.
Other - Org Name:ROSEWOOD REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:2045 SILVERADA BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-2051
Mailing Address - Country:US
Mailing Address - Phone:775-359-3161
Mailing Address - Fax:775-331-2878
Practice Address - Street 1:2045 SILVERADA BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-2051
Practice Address - Country:US
Practice Address - Phone:775-359-3161
Practice Address - Fax:775-331-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV295020Medicare Oscar/Certification