Provider Demographics
NPI:1699837229
Name:BERRYMAN HEALTH, INC
Entity Type:Organization
Organization Name:BERRYMAN HEALTH, INC
Other - Org Name:HEALDSBURG SENIOR LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. POLICY AND GOVERNMENT RELATION
Authorized Official - Prefix:MS
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINCLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0153
Mailing Address - Street 1:255 E 400 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2846
Mailing Address - Country:US
Mailing Address - Phone:801-325-0153
Mailing Address - Fax:801-596-9001
Practice Address - Street 1:725 GROVE ST
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-4756
Practice Address - Country:US
Practice Address - Phone:707-433-4877
Practice Address - Fax:707-433-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000014314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55820FMedicaid
CA555820Medicare Oscar/Certification