1205835477 NPI number — WALNUT WHITNEY CARE CENTER, INC.

Table of content: (NPI 1205835477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205835477 NPI number — WALNUT WHITNEY CARE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALNUT WHITNEY CARE CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205835477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4020 SIERRA COLLEGE BLVD
Provider Second Line Business Mailing Address:
STE 190
Provider Business Mailing Address City Name:
ROCKLIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95677-3906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-624-6230
Provider Business Mailing Address Fax Number:
916-624-6249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3529 WALNUT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMICHAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95608-3049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-488-8601
Provider Business Practice Location Address Fax Number:
916-488-0695
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BEAR
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
916-624-6230

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  030000114 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZR06410G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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