Provider Demographics
NPI:1831573856
Name:CUCUMBER HOLDINGS, LLC
Entity type:Organization
Organization Name:CUCUMBER HOLDINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-988-3319
Mailing Address - Street 1:262 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21820 CRAGGY VIEW ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2909
Practice Address - Country:US
Practice Address - Phone:818-882-8233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA920000019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831573856Medicaid
CA555574Medicare Oscar/Certification