Provider Demographics
NPI:1891914784
Name:ST JOHN RETIREMENT VILLAGE
Entity Type:Organization
Organization Name:ST JOHN RETIREMENT VILLAGE
Other - Org Name:STOLLWOOD CONVALESCENT HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-662-1290
Mailing Address - Street 1:135 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2701
Mailing Address - Country:US
Mailing Address - Phone:530-662-1290
Mailing Address - Fax:530-662-4639
Practice Address - Street 1:135 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2701
Practice Address - Country:US
Practice Address - Phone:530-662-1290
Practice Address - Fax:530-662-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000099314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA206571047Medicaid
CA05-6138Medicare ID - Type Unspecified