MEDICARE: CONGREGATIONAL CHURCH RETIREMENT COMMUNITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	030000172	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083619365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONGREGATIONAL CHURCH RETIREMENT COMMUNITY

Provider Business Mailing Address
First Line	:	750 AUBURN RAVINE RD
Second Line	:
City	:	AUBURN
State	:	CA
Zip	:	95603-3820
Country	:	US
Telephone Number	:	530-823-6131
Fax Number	:	530-823-9510

Provider Business Practice Location Address
First Line	:	750 AUBURN RAVINE RD
Second Line	:
City	:	AUBURN
State	:	CA
Zip	:	95603-3820
Country	:	US
Telephone Number	:	530-823-6131
Fax Number	:	530-823-9510

Authorized Official
Title or Position	:	V.P. HEALTHCARE OPERATIONS
Name	:	PETER PEABODY
Credential	:
Telephone Number	:	562-257-5107

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	02/03/2009

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