Healthcare Provider Details

I. General information

NPI: 1710165162
Provider Name (Legal Business Name): REDWOD SHORE EMPIRE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 WHITMORE LN
UKIAH CA
95482-6931
US

IV. Provider business mailing address

3141 ELYSE CT
MODESTO CA
95355-8692
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-5725
  • Fax:
Mailing address:
  • Phone: 209-576-5725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. THRESIAMMA J PALLIVATHUCAL
Title or Position: OWNER
Credential: RN
Phone: 209-576-5725