Healthcare Provider Details

I. General information

NPI: 1134003411
Provider Name (Legal Business Name): ROOSEVELT LAKE HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 COFFEE RD
MODESTO CA
95355-2703
US

IV. Provider business mailing address

16544 FRANZEN FARM RD
SAN DIEGO CA
92127-2240
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1775
  • Fax:
Mailing address:
  • Phone: 858-798-5700
  • 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: TOBY TILFORD
Title or Position: CEO
Credential:
Phone: 858-774-8342