MEDICARE: MONTE VISTA LODGE LIMITED PARTNERSHIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility		CA
2	314000000X	Skilled Nursing Facility		CA

General Provider Information

NPI Number	:	1649212986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTE VISTA LODGE LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	1107 HAZELTINE BLVD
Second Line	:	SUITE 200
City	:	CHASKA
State	:	MN
Zip	:	55318-1009
Country	:	US
Telephone Number	:	952-361-8000
Fax Number	:	952-361-8058

Provider Business Practice Location Address
First Line	:	2211 MASSACHUSETTS AVE
Second Line	:
City	:	LEMON GROVE
State	:	CA
Zip	:	91945-3616
Country	:	US
Telephone Number	:	619-465-1331
Fax Number	:	619-465-2426

Authorized Official
Title or Position	:	PRESIDENT OF GENERAL PARTNER
Name	:	MR. JOHN B GOODMAN
Credential	:
Telephone Number	:	952-361-8000

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	09/11/2025

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