Provider Demographics
NPI:1689662330
Name:WESTGATE PREMIER HEALTHCARE SERVICES, INC.
Entity Type:Organization
Organization Name:WESTGATE PREMIER HEALTHCARE SERVICES, INC.
Other - Org Name:AMBERWOOD GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDIL
Authorized Official - Middle Name:V
Authorized Official - Last Name:BASA
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:408-253-7502
Mailing Address - Street 1:1601 PETERSEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4844
Mailing Address - Country:US
Mailing Address - Phone:408-253-7502
Mailing Address - Fax:408-252-6034
Practice Address - Street 1:1601 PETERSEN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4844
Practice Address - Country:US
Practice Address - Phone:408-253-7502
Practice Address - Fax:408-252-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05750HMedicaid
CAZZR05750HMedicaid