Provider Demographics
NPI:1417939125
Name:LAKE OROVILLE COUNTRY RETIREMENT
Entity Type:Organization
Organization Name:LAKE OROVILLE COUNTRY RETIREMENT
Other - Org Name:COUNTRY CREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:530-533-7857
Mailing Address - Street 1:55 CONCORDIA LN
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6347
Mailing Address - Country:US
Mailing Address - Phone:530-533-7857
Mailing Address - Fax:530-533-7887
Practice Address - Street 1:55 CONCORDIA LN
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6347
Practice Address - Country:US
Practice Address - Phone:530-533-7857
Practice Address - Fax:530-533-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45001619310400000X
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55802FMedicaid
CA555802Medicare ID - Type Unspecified