Provider Demographics
NPI:1316484439
Name:CACHE CREEK LODGE
Entity type:Organization
Organization Name:CACHE CREEK LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-662-5727
Mailing Address - Street 1:435 ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2665
Mailing Address - Country:US
Mailing Address - Phone:530-662-5727
Mailing Address - Fax:
Practice Address - Street 1:435 ASPEN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2665
Practice Address - Country:US
Practice Address - Phone:530-662-5727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CACHE CREEK LODGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-26
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA03430315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty