Provider Demographics
NPI:1841336534
Name:WINDSOR COUNTRY DRIVE CARE CENTER, LLC
Entity type:Organization
Organization Name:WINDSOR COUNTRY DRIVE CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-385-1090
Mailing Address - Street 1:2500 COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5356
Mailing Address - Country:US
Mailing Address - Phone:510-792-4242
Mailing Address - Fax:510-797-2074
Practice Address - Street 1:2500 COUNTRY DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5356
Practice Address - Country:US
Practice Address - Phone:510-792-4242
Practice Address - Fax:510-797-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05885IMedicaid
CA055885Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER