Provider Demographics
NPI:1609857275
Name:GERI-CARE IV, LLC
Entity Type:Organization
Organization Name:GERI-CARE IV, LLC
Other - Org Name:ANTELOPE VALLEY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:TERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:661-949-5524
Mailing Address - Street 1:44567 15TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2803
Mailing Address - Country:US
Mailing Address - Phone:661-949-5524
Mailing Address - Fax:661-949-5140
Practice Address - Street 1:44567 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2803
Practice Address - Country:US
Practice Address - Phone:661-949-5524
Practice Address - Fax:661-949-5140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA920000122314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTM90003GMedicaid
CALTM90003GMedicaid