Provider Demographics
NPI:1811982929
Name:CHANCELLOR HEALTH CARE OF CA
Entity type:Organization
Organization Name:CHANCELLOR HEALTH CARE OF CA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:909-796-0235
Mailing Address - Street 1:25383 COLE ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3103
Mailing Address - Country:US
Mailing Address - Phone:909-796-0235
Mailing Address - Fax:909-796-6366
Practice Address - Street 1:25383 COLE ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3103
Practice Address - Country:US
Practice Address - Phone:909-796-0235
Practice Address - Fax:909-796-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22T05299HMedicaid
CA22T05299HMedicaid