Provider Demographics
NPI: | 1720632359 |
---|---|
Name: | CALAVARAS CREEK HEALTHCARE LLC |
Entity Type: | Organization |
Organization Name: | CALAVARAS CREEK HEALTHCARE LLC |
Other - Org Name: | PECAN VALLEY REHABILITATION AND HEALTHCARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | TREASURER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | SOON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BURNAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 949-540-1249 |
Mailing Address - Street 1: | 3838 E SOUTHCROSS BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN ANTONIO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78222-3556 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 210-581-2273 |
Mailing Address - Fax: | 210-572-6994 |
Practice Address - Street 1: | 3838 E SOUTHCROSS BLVD |
Practice Address - Street 2: | |
Practice Address - City: | SAN ANTONIO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78222-3556 |
Practice Address - Country: | US |
Practice Address - Phone: | 210-581-2273 |
Practice Address - Fax: | 210-572-6994 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-07-31 |
Last Update Date: | 2023-01-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |