Provider Demographics
NPI:1770903775
Name:DEPARTMENT OF VETERANS AFFAIRS OF THE STATE OF CALIFORNIA
Entity type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS OF THE STATE OF CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMPERIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-493-4226
Mailing Address - Street 1:PO BOX 942895
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:94295-0001
Mailing Address - Country:US
Mailing Address - Phone:916-657-9349
Mailing Address - Fax:916-653-1795
Practice Address - Street 1:2811 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-2307
Practice Address - Country:US
Practice Address - Phone:559-493-4248
Practice Address - Fax:559-493-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107206701310400000X
CA550002640314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555900OtherMEDICARE