Provider Demographics
NPI:1710165162
Name:REDWOD SHORE EMPIRE, LLC
Entity Type:Organization
Organization Name:REDWOD SHORE EMPIRE, LLC
Other - Org Name:REDWOOD EMPIRE NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THRESIAMMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALLIVATHUCAL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:209-576-5725
Mailing Address - Street 1:3141 ELYSE CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8692
Mailing Address - Country:US
Mailing Address - Phone:209-576-5725
Mailing Address - Fax:
Practice Address - Street 1:131 WHITMORE LN
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6931
Practice Address - Country:US
Practice Address - Phone:209-576-5725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility