Provider Demographics
NPI:1972594463
Name:CORE CARE V A CA LIMITED
Entity type:Organization
Organization Name:CORE CARE V A CA LIMITED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ELWOOD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:760-704-6255
Mailing Address - Street 1:2525 BREA BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2787
Mailing Address - Country:US
Mailing Address - Phone:714-256-1000
Mailing Address - Fax:714-256-8014
Practice Address - Street 1:2525 BREA BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2787
Practice Address - Country:US
Practice Address - Phone:714-256-1000
Practice Address - Fax:714-256-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300613274310400000X
CA060000329314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555515Medicare Oscar/Certification