Basic Information
| Provider Information | |||||||||
| NPI: | 1841336534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDSOR COUNTRY DRIVE CARE CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINDSOR COUNTRY DRIVE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 COUNTRY DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945365356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107924242 | ||||||||
| FaxNumber: | 5107972074 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 COUNTRY DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945365356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107924242 | ||||||||
| FaxNumber: | 5107972074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FIEGEN | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3103851090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZR05885I | 05 | CA | MEDICAID |