Provider Demographics
NPI:1841354354
Name:CASA PACIFICA
Entity type:Organization
Organization Name:CASA PACIFICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-489-0430
Mailing Address - Street 1:23442 EL TORO RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6979
Mailing Address - Country:US
Mailing Address - Phone:949-472-4700
Mailing Address - Fax:949-855-0428
Practice Address - Street 1:23442 EL TORO RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6979
Practice Address - Country:US
Practice Address - Phone:949-472-4700
Practice Address - Fax:949-855-0428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300606831310400000X
CA060000246314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555391Medicaid
CA555391Medicare ID - Type Unspecified