Provider Demographics
NPI:1083836274
Name:SANTA ROSA FAMILY CARE CENTER, A NURSING CORPORATION
Entity type:Organization
Organization Name:SANTA ROSA FAMILY CARE CENTER, A NURSING CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, CFO, SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:SIFUENTES
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:323-981-2930
Mailing Address - Street 1:5015 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-3116
Mailing Address - Country:US
Mailing Address - Phone:323-981-2930
Mailing Address - Fax:323-981-2035
Practice Address - Street 1:5015 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3116
Practice Address - Country:US
Practice Address - Phone:323-981-2930
Practice Address - Fax:323-981-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGNP000150Medicaid