Provider Demographics
NPI:1124170519
Name:CF SUSANVILLE, LLC
Entity type:Organization
Organization Name:CF SUSANVILLE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-651-1808
Mailing Address - Street 1:2005 RIVER STREET
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130
Mailing Address - Country:US
Mailing Address - Phone:530-257-5341
Mailing Address - Fax:530-257-8150
Practice Address - Street 1:2005 RIVER STREET
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130
Practice Address - Country:US
Practice Address - Phone:530-257-5341
Practice Address - Fax:530-257-8150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000058314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06231JMedicaid
CAZZR06231JMedicaid