Provider Demographics
NPI:1831142397
Name:ELEVEN PACK MANAGEMENT CORP.
Entity Type:Organization
Organization Name:ELEVEN PACK MANAGEMENT CORP.
Other - Org Name:BRIGHTON GARDENS OF RANCHO MIRAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-340-5999
Mailing Address - Street 1:7900 WESTPARK DR
Mailing Address - Street 2:T-900, ATTN: MEDICARE BILLING, M. GARCIA
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4242
Mailing Address - Country:US
Mailing Address - Phone:703-854-0823
Mailing Address - Fax:703-854-0164
Practice Address - Street 1:72201 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4001
Practice Address - Country:US
Practice Address - Phone:760-340-5999
Practice Address - Fax:760-340-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
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
CA555575Medicare ID - Type Unspecified