MEDICARE: CHANCELLOR HEALTH CARE OF CALIFORNIA IV, INC.

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	:	1982035606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANCELLOR HEALTH CARE OF CALIFORNIA IV, INC.

Provider Business Mailing Address
First Line	:	115 JOHNSON ST
Second Line	:
City	:	WINDSOR
State	:	CA
Zip	:	95492-7435
Country	:	US
Telephone Number	:	707-687-1919
Fax Number	:	707-687-1912

Provider Business Practice Location Address
First Line	:	1320 WINDLASS DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21220-4100
Country	:	US
Telephone Number	:	410-918-2139
Fax Number	:	410-687-9909

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	CLUNEY STAGG
Credential	:
Telephone Number	:	707-687-1919

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	12/05/2013

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