Provider Demographics
NPI:1881211852
Name:CHANCELLOR HEALTH CARE OF CALIFORNIA IX, INC.
Entity Type:Organization
Organization Name:CHANCELLOR HEALTH CARE OF CALIFORNIA IX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF FINACIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLUNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-291-3582
Mailing Address - Street 1:115 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7435
Mailing Address - Country:US
Mailing Address - Phone:707-291-3582
Mailing Address - Fax:707-687-1912
Practice Address - Street 1:14550 SE VISTA LN
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-1731
Practice Address - Country:US
Practice Address - Phone:503-659-2325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR527025Medicaid