Provider Demographics
NPI:1669661716
Name:PETALUMA SKILLED NURSING & WELLNESS CENTRE, LLC
Entity Type:Organization
Organization Name:PETALUMA SKILLED NURSING & WELLNESS CENTRE, LLC
Other - Org Name:COUNTRY VILLA PETALUMA HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:REISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-574-3733
Mailing Address - Street 1:5120 W GOLDLEAF CIR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1292
Mailing Address - Country:US
Mailing Address - Phone:310-574-3733
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:523 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4011
Practice Address - Country:US
Practice Address - Phone:707-763-2457
Practice Address - Fax:707-765-2176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55703FMedicaid
CALTC55703FMedicaid