Provider Demographics
NPI:1124442520
Name:SOLIDUM CARE HOME ICF DDN2
Entity type:Organization
Organization Name:SOLIDUM CARE HOME ICF DDN2
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLIDUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-474-6785
Mailing Address - Street 1:2114 CODY CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1212
Mailing Address - Country:US
Mailing Address - Phone:209-474-6785
Mailing Address - Fax:
Practice Address - Street 1:9559 COLINGTON PL
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-5013
Practice Address - Country:US
Practice Address - Phone:209-474-6785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001684313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550001684Medicaid