Provider Demographics
NPI:1053563536
Name:SHIRLEY'S ICF DD N NO 5
Entity type:Organization
Organization Name:SHIRLEY'S ICF DD N NO 5
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAPASIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:209-607-9380
Mailing Address - Street 1:1182 DUVALL CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3581
Mailing Address - Country:US
Mailing Address - Phone:209-475-9829
Mailing Address - Fax:209-475-9845
Practice Address - Street 1:9565 COLINGTON PL
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-5013
Practice Address - Country:US
Practice Address - Phone:209-952-6027
Practice Address - Fax:209-952-7829
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHIRLEY'S CARE HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5500000686313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55G247Medicare Oscar/Certification
55G389Medicare Oscar/Certification
CA05G976Medicare Oscar/Certification