Provider Demographics
NPI:1942256391
Name:LODI SKILLED NURSING SERVICES, INC.
Entity Type:Organization
Organization Name:LODI SKILLED NURSING SERVICES, INC.
Other - Org Name:FAIRMONT REHABILITATION HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-373-8373
Mailing Address - Street 1:25910 ACERO STE 350
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7908
Mailing Address - Country:US
Mailing Address - Phone:949-441-9258
Mailing Address - Fax:
Practice Address - Street 1:950 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-368-0693
Practice Address - Fax:209-339-9759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000039314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05242IMedicaid
CAZZR05242IMedicaid