Provider Demographics
NPI:1790768083
Name:ANAHEIM TERRACE CARE CENTER, LLC
Entity Type:Organization
Organization Name:ANAHEIM TERRACE CARE CENTER, LLC
Other - Org Name:ANAHEIM TERRACE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:141 S. KNOTT AVE.
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1406
Mailing Address - Country:US
Mailing Address - Phone:714-821-7310
Mailing Address - Fax:
Practice Address - Street 1:141 S. KNOTT AVE.
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1406
Practice Address - Country:US
Practice Address - Phone:714-821-7310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-21
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000647314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT056076JMedicaid
CAZZT056076JMedicaid