Healthcare Provider Details

I. General information

NPI: 1912050956
Provider Name (Legal Business Name): SOUTH CAPITOL COTTAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2007
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15054 DAISY RD
ADELANTO CA
92301-4824
US

IV. Provider business mailing address

1801 DE CARMEN DR
COLTON CA
92324-6248
US

V. Phone/Fax

Practice location:
  • Phone: 951-662-3026
  • Fax:
Mailing address:
  • Phone: 951-662-3026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS CAROL FRAZIER
Title or Position: PRESIDENT
Credential: LVN
Phone: 951-662-3026