Provider Demographics
NPI:1427129253
Name:STEPHEN R CARTER
Entity type:Organization
Organization Name:STEPHEN R CARTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NHA OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:NURSING HOME ADMINIS
Authorized Official - Phone:619-277-4350
Mailing Address - Street 1:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-0427
Mailing Address - Country:US
Mailing Address - Phone:619-443-3886
Mailing Address - Fax:
Practice Address - Street 1:12436 ROYAL RD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-1723
Practice Address - Country:US
Practice Address - Phone:619-443-3886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000090314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA080000090OtherFACILITY LICENSE NUMBER
CA206370165OtherOSHPD NUMBER
CAZZT18550FMedicaid
CAZZT18550GMedicaid