Provider Demographics
NPI:1669594867
Name:EDEN VALLEY CARE CENTER
Entity type:Organization
Organization Name:EDEN VALLEY CARE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:IDA
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-678-2462
Mailing Address - Street 1:612 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOLEDAD
Mailing Address - State:CA
Mailing Address - Zip Code:93960-2533
Mailing Address - Country:US
Mailing Address - Phone:831-678-2462
Mailing Address - Fax:
Practice Address - Street 1:612 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960-2533
Practice Address - Country:US
Practice Address - Phone:831-678-2462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000327314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55538FMedicaid
CA555538Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION #