Healthcare Provider Details

I. General information

NPI: 1427582725
Provider Name (Legal Business Name): THE LAKES AT BLACK CREEK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 SANGUINETTI CT
COPPEROPOLIS CA
95228-9459
US

IV. Provider business mailing address

7260 OBYRNES FERRY RD
COPPEROPOLIS CA
95228-9761
US

V. Phone/Fax

Practice location:
  • Phone: 209-325-8506
  • Fax:
Mailing address:
  • Phone: 209-325-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number050005BP
License Number StateCA

VIII. Authorized Official

Name: NICHOLAS J MCNULTY
Title or Position: COMPLIANCE DIRECTOR
Credential:
Phone: 209-768-5871