Provider Demographics
NPI:1811963028
Name:WINDSOR HEALTHCARE GOLDEN PALMS LLC
Entity type:Organization
Organization Name:WINDSOR HEALTHCARE GOLDEN PALMS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:FIEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-385-1090
Mailing Address - Street 1:1201 34TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2416
Mailing Address - Country:US
Mailing Address - Phone:619-232-2946
Mailing Address - Fax:619-232-4665
Practice Address - Street 1:1201 34TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2416
Practice Address - Country:US
Practice Address - Phone:619-232-2946
Practice Address - Fax:619-232-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090000052314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06182KMedicaid
CA056182Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION