MEDICARE: BALBOA ISLAND, 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	:	1982439568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALBOA ISLAND, LLC

Provider Business Mailing Address
First Line	:	599 MENLO DR STE 200
Second Line	:
City	:	ROCKLIN
State	:	CA
Zip	:	95765-3725
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2850 SIERRA SUNRISE TER
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95928-8401
Country	:	US
Telephone Number	:	530-894-1010
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	RYAN WILLIAMS
Credential	:
Telephone Number	:	916-945-1248

Provider Enumeration Date	:	09/04/2024
Last Update Date	:	09/04/2024

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Directions to “BALBOA ISLAND, LLC ” Practice Location

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