Provider Demographics
NPI:1700963956
Name:SURPRISE VALLEY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SURPRISE VALLEY HOSPITAL DISTRICT
Other - Org Name:SURPRISE VALLEY COMMUNITY HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-279-6111
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96104-0246
Mailing Address - Country:US
Mailing Address - Phone:530-279-6111
Mailing Address - Fax:530-279-2680
Practice Address - Street 1:741 N MAIN
Practice Address - Street 2:MAIN & WASHINGTON ST
Practice Address - City:CEDARVILLE
Practice Address - State:CA
Practice Address - Zip Code:96104
Practice Address - Country:US
Practice Address - Phone:530-279-6111
Practice Address - Fax:530-279-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA311Z00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55221FMedicaid
CA555221Medicare ID - Type UnspecifiedMEDICARE EXTENDED CARE