Provider Demographics
NPI:1669473310
Name:SHADOWBROOK HEALTH CARE, INC.
Entity Type:Organization
Organization Name:SHADOWBROOK HEALTH CARE, INC.
Other - Org Name:SHADOWBROOK HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-897-5100
Mailing Address - Street 1:1 GILMORE LN
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-5147
Mailing Address - Country:US
Mailing Address - Phone:530-534-1353
Mailing Address - Fax:530-534-0632
Practice Address - Street 1:1 GILMORE LN
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-5147
Practice Address - Country:US
Practice Address - Phone:530-534-1353
Practice Address - Fax:530-534-0632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000059314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05612IMedicaid
CA055612Medicare Oscar/Certification