Provider Demographics
NPI:1710040795
Name:SOUTH VALLEY HEALTHCARE, INC.
Entity type:Organization
Organization Name:SOUTH VALLEY HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER OF MANAGEMENT COMPANY
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:27101 PUERTA REAL
Mailing Address - Street 2:SUITE 450
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8518
Mailing Address - Country:US
Mailing Address - Phone:949-487-9500
Mailing Address - Fax:949-540-1966
Practice Address - Street 1:4782 HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5444
Practice Address - Country:US
Practice Address - Phone:949-487-9500
Practice Address - Fax:949-540-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2007-NCF-78400314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT465109Medicare Oscar/Certification