Provider Demographics
NPI:1811923303
Name:12072 TRASK, INC.
Entity type:Organization
Organization Name:12072 TRASK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:URANGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-534-1943
Mailing Address - Street 1:12072 TRASK AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-3821
Mailing Address - Country:US
Mailing Address - Phone:714-534-1942
Mailing Address - Fax:714-534-0967
Practice Address - Street 1:12072 TRASK AVE
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-3821
Practice Address - Country:US
Practice Address - Phone:714-534-1942
Practice Address - Fax:714-534-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38640058314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05575HMedicaid
CA38640058OtherSTATE LICENSE NUMBER
CALTC70174FMedicaid
CAZZT05575HMedicaid