MEDICARE: EAGLE VALLEY CARE CENTRE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1093595142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE VALLEY CARE CENTRE, LLC

Provider Business Mailing Address
First Line	:	1149 FAIR WEATHER CIR
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94518-1939
Country	:	US
Telephone Number	:	925-483-1096
Fax Number	:	925-955-9000

Provider Business Practice Location Address
First Line	:	1807 E LONG ST
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89706-3214
Country	:	US
Telephone Number	:	925-483-1096
Fax Number	:	925-955-9000

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. AFRODESIA CUBETA LOPOZ
Credential	:	ADMINISTRATOR
Telephone Number	:	925-483-1096

Provider Enumeration Date	:	10/04/2023
Last Update Date	:	10/04/2023

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