Provider Demographics
NPI:1356765218
Name:GRASS VALLEY EXTENDED CARE INC
Entity type:Organization
Organization Name:GRASS VALLEY EXTENDED CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KULDIP
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-273-8452
Mailing Address - Street 1:280 SIERRA COLLEGE BLVD
Mailing Address - Street 2:201
Mailing Address - City:GRASS VELLY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5763
Mailing Address - Country:US
Mailing Address - Phone:530-273-8452
Mailing Address - Fax:530-477-5182
Practice Address - Street 1:280 SIERRA COLLEGE DR
Practice Address - Street 2:201
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5763
Practice Address - Country:US
Practice Address - Phone:530-273-8452
Practice Address - Fax:530-477-5182
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A-KULDIP GILL MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization