Provider Demographics
NPI:1598089351
Name:GRIDLEY HEALTHCARE & WELLNESS CENTRE, LLC
Entity Type:Organization
Organization Name:GRIDLEY HEALTHCARE & WELLNESS CENTRE, LLC
Other - Org Name:GRIDLEY HEALTHCARE & WELLNESS CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT - CAMS
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:246 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-2216
Mailing Address - Country:US
Mailing Address - Phone:530-846-6266
Mailing Address - Fax:530-846-0668
Practice Address - Street 1:246 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-2216
Practice Address - Country:US
Practice Address - Phone:530-846-6266
Practice Address - Fax:530-846-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555124OtherMEDICARE
CA555124Medicare Oscar/Certification