Healthcare Provider Details

I. General information

NPI: 1396081212
Provider Name (Legal Business Name): GHC OF LOMPOC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 W NORTH AVE
LOMPOC CA
93436-3961
US

IV. Provider business mailing address

1428 W NORTH AVE
LOMPOC CA
93436-3961
US

V. Phone/Fax

Practice location:
  • Phone: 805-735-4010
  • Fax:
Mailing address:
  • Phone: 805-735-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number050000587
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierLTC9008F
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: THOMAS OLDS JR.
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 714-241-5600