Healthcare Provider Details

I. General information

NPI: 1891597043
Provider Name (Legal Business Name): CIMMERON TRAIL RCFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10415 CIMMERON TRAIL DR
ADELANTO CA
92301-2214
US

IV. Provider business mailing address

18857 RAVENHURST WAY
RIVERSIDE CA
92504-9413
US

V. Phone/Fax

Practice location:
  • Phone: 213-210-5773
  • Fax:
Mailing address:
  • Phone: 213-210-5773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: EUGENE CARSON III
Title or Position: LICENSEE
Credential:
Phone: 213-210-5773