Provider Demographics
NPI:1619976131
Name:C STREET HEALTH ASSOCIATES LLC
Entity Type:Organization
Organization Name:C STREET HEALTH ASSOCIATES LLC
Other - Org Name:GLENWOOD CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT OFFICER
Authorized Official - Prefix:MS
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 1:1300 N C ST
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-4006
Mailing Address - Country:US
Mailing Address - Phone:805-983-0305
Mailing Address - Fax:805-983-2514
Practice Address - Street 1:1300 N C ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-4006
Practice Address - Country:US
Practice Address - Phone:805-983-0305
Practice Address - Fax:805-983-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000033314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55458GMedicaid
CA555458Medicare Oscar/Certification