MEDICARE: FERNWOOD CARE FACILITY LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1619832193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FERNWOOD CARE FACILITY LLC

Provider Business Mailing Address
First Line	:	116 FERNWOOD CT
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-6070
Country	:	US
Telephone Number	:	707-321-3711
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 FERNWOOD CT
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-6070
Country	:	US
Telephone Number	:	707-321-3711
Fax Number	:

Authorized Official
Title or Position	:	LICENSEE
Name	:	ANTONIO GONZALES CRUZ
Credential	:
Telephone Number	:	707-321-3711

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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