Provider Demographics
NPI:1982035606
Name:CHANCELLOR HEALTH CARE OF CALIFORNIA IV, INC.
Entity type:Organization
Organization Name:CHANCELLOR HEALTH CARE OF CALIFORNIA IV, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CLUNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-687-1919
Mailing Address - Street 1:115 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7435
Mailing Address - Country:US
Mailing Address - Phone:707-687-1919
Mailing Address - Fax:707-687-1912
Practice Address - Street 1:1320 WINDLASS DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-4100
Practice Address - Country:US
Practice Address - Phone:410-918-2139
Practice Address - Fax:410-687-9909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANCELLOR HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility