MEDICARE: RUSSIAN RIVER HOLDINGS 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1922795293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSIAN RIVER HOLDINGS LLC

Provider Business Mailing Address
First Line	:	16544 FRANZEN FARM RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-2240
Country	:	US
Telephone Number	:	858-798-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 WALNUT ST
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95695-3137
Country	:	US
Telephone Number	:	858-798-5700
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TOBY TILFORD
Credential	:
Telephone Number	:	858-798-5700

Provider Enumeration Date	:	04/18/2023
Last Update Date	:	05/29/2025

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Directions to “RUSSIAN RIVER HOLDINGS LLC ” Practice Location

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