Provider Demographics
NPI:1962034496
Name:JACKSON RIVER HOLDINGS LLC
Entity Type:Organization
Organization Name:JACKSON RIVER HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-331-3177
Mailing Address - Street 1:16885 W BERNARDO DR STE 216
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1620
Mailing Address - Country:US
Mailing Address - Phone:760-331-3177
Mailing Address - Fax:
Practice Address - Street 1:752 HOLMES ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4229
Practice Address - Country:US
Practice Address - Phone:925-447-2280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility