Provider Demographics
NPI:1861493504
Name:BRENTWOOD SKILLED NURSING CENTER, INC.
Entity Type:Organization
Organization Name:BRENTWOOD SKILLED NURSING CENTER, INC.
Other - Org Name:BRENTWOOD SKILLED NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-897-5100
Mailing Address - Street 1:1795 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-3645
Mailing Address - Country:US
Mailing Address - Phone:530-527-2046
Mailing Address - Fax:530-527-8737
Practice Address - Street 1:1795 WALNUT ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-3645
Practice Address - Country:US
Practice Address - Phone:530-527-2046
Practice Address - Fax:530-527-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000043314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05489HMedicaid
CAZZR05489HMedicaid