Provider Demographics
NPI:1477795144
Name:SP MARAVILLA LLC
Entity Type:Organization
Organization Name:SP MARAVILLA LLC
Other - Org Name:MARAVILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESID
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:WICKLIFFE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-792-9300
Mailing Address - Street 1:5486 CALLE REAL
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111-1645
Mailing Address - Country:US
Mailing Address - Phone:805-967-1965
Mailing Address - Fax:
Practice Address - Street 1:5486 CALLE REAL
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111-1645
Practice Address - Country:US
Practice Address - Phone:805-967-1965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428501038310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility