Healthcare Provider Details

I. General information

NPI: 1780490821
Provider Name (Legal Business Name): CDR RANCHO CUCAMONGA TRS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9428 19TH ST
ALTA LOMA CA
91701-4108
US

IV. Provider business mailing address

9428 19TH ST
ALTA LOMA CA
91701-4108
US

V. Phone/Fax

Practice location:
  • Phone: 909-481-2600
  • Fax:
Mailing address:
  • Phone: 909-481-2600
  • 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: PETER ELWELL
Title or Position: LLC MEMBER
Credential:
Phone: 949-231-9660