Eagle Lake Village

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

EAGLE LAKE VILLAGE

Practice address

2001 Paul Bunyan Rd.
Susanville, CA 96130

Phone

(530) 457-4380

NPI assigned

Nov 17, 2022

Last updated

Nov 17, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark J Cimino

Title

Ceo

Phone

(916) 704-6275

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1668643200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1668643200000",
    "number": "1114636230",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2001 PAUL BUNYAN RD.",
            "city": "SUSANVILLE",
            "state": "CA",
            "postal_code": "96130",
            "telephone_number": "530-457-4380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2001 PAUL BUNYAN RD.",
            "city": "SUSANVILLE",
            "state": "CA",
            "postal_code": "96130",
            "telephone_number": "530-457-4380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE LAKE VILLAGE",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-11-17",
        "last_updated": "2022-11-17",
        "certification_date": "2022-11-17",
        "status": "A",
        "authorized_official_last_name": "CIMINO",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "916-704-6275"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Darlene Amy Dougherty, R.D.
• Camcheri Lynn Downing
• John C Dozier Jr., M.D.
• Veryl Drury, D.D.S.
• Bethany Duvarney
• Timothy S Eckford, M.D.
• Karen Embree-Smith
• Kenna English
• Environmental Alternatives (EA Family Services)
• Environmental Alternatives Susanville (EA Family Services)

• Assisted Living Facility in Susanville, CA
• Providers in Susanville, CA by specialty
• Assisted Living Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 17, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.