Provider Demographics
NPI:1790036812
Name:CACHE CREEK LODGE INC
Entity Type:Organization
Organization Name:CACHE CREEK LODGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PETER
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARRTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-662-5727
Mailing Address - Street 1:435 ASPEN STREET
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2665
Mailing Address - Country:US
Mailing Address - Phone:530-668-1198
Mailing Address - Fax:
Practice Address - Street 1:435 ASPEN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2665
Practice Address - Country:US
Practice Address - Phone:530-662-5727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790036812Medicaid