Provider Demographics
NPI:1982691366
Name:PACIFIC HEALTHCARE & REHABILITATION, LLC
Entity Type:Organization
Organization Name:PACIFIC HEALTHCARE & REHABILITATION, LLC
Other - Org Name:PACIFIC HEALTHCARE & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RD, NHS
Authorized Official - Phone:707-443-9767
Mailing Address - Street 1:2211 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3214
Mailing Address - Country:US
Mailing Address - Phone:707-443-9767
Mailing Address - Fax:707-441-8447
Practice Address - Street 1:2211 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3214
Practice Address - Country:US
Practice Address - Phone:707-443-9767
Practice Address - Fax:707-441-8447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000051314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05334KMedicaid
CAZZR05334KMedicaid