Provider Demographics
NPI:1679505572
Name:BLUFF ENTERPRISES CORP
Entity Type:Organization
Organization Name:BLUFF ENTERPRISES CORP
Other - Org Name:FOLSOM CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-985-3641
Mailing Address - Street 1:510 MILL ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-2607
Mailing Address - Country:US
Mailing Address - Phone:916-985-3641
Mailing Address - Fax:916-985-7231
Practice Address - Street 1:510 MILL ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2607
Practice Address - Country:US
Practice Address - Phone:916-985-3641
Practice Address - Fax:916-985-7231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05173FMedicaid
055173Medicare ID - Type Unspecified