Healthcare Provider Details

I. General information

NPI: 1902891641
Provider Name (Legal Business Name): CASA PACIFICA NURSING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 SOUTH HARBOR BOULEVARD
ANAHEIM CA
92805
US

IV. Provider business mailing address

861 SOUTH HARBOR BOULEVARD
ANAHEIM CA
92805
US

V. Phone/Fax

Practice location:
  • Phone: 714-635-8131
  • Fax: 714-635-8960
Mailing address:
  • Phone: 714-635-8131
  • Fax: 714-635-8960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number060000096
License Number StateCA

VIII. Authorized Official

Name: JACOB WINTNER
Title or Position: MANAGER
Credential:
Phone: 323-651-1808