Healthcare Provider Details

I. General information

NPI: 1962034496
Provider Name (Legal Business Name): JACKSON RIVER HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 HOLMES ST
LIVERMORE CA
94550-4229
US

IV. Provider business mailing address

16885 W BERNARDO DR STE 216
SAN DIEGO CA
92127-1620
US

V. Phone/Fax

Practice location:
  • Phone: 925-447-2280
  • Fax:
Mailing address:
  • Phone: 760-331-3177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MYRNA DE GUZMAN
Title or Position: CORPORATE CONTROLLER
Credential:
Phone: 760-331-3177