Healthcare Provider Details

I. General information

NPI: 1417939125
Provider Name (Legal Business Name): LAKE OROVILLE COUNTRY RETIREMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CONCORDIA LN
OROVILLE CA
95966-6347
US

IV. Provider business mailing address

55 CONCORDIA LN
OROVILLE CA
95966-6347
US

V. Phone/Fax

Practice location:
  • Phone: 530-533-7857
  • Fax: 530-533-7887
Mailing address:
  • Phone: 530-533-7857
  • Fax: 530-533-7887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number45001619
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. LARRY EUGENE BRADLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: NHA
Phone: 530-533-7857