Provider Demographics
NPI:1932212065
Name:DIVERSIFIED SUSTAINABLE SYSTEMS
Entity type:Organization
Organization Name:DIVERSIFIED SUSTAINABLE SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-435-2963
Mailing Address - Street 1:3031 STANFORD RANCH RD
Mailing Address - Street 2:SUITE 2, #220
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5554
Mailing Address - Country:US
Mailing Address - Phone:916-435-2963
Mailing Address - Fax:916-435-2964
Practice Address - Street 1:3031 STANFORD RANCH RD
Practice Address - Street 2:SUITE 2, #220
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-5554
Practice Address - Country:US
Practice Address - Phone:916-435-2963
Practice Address - Fax:916-435-2964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66004314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG66004Medicaid
CAZZZ24568ZMedicare ID - Type UnspecifiedMEDICARE
CAE29236Medicare UPIN