Healthcare Provider Details

I. General information

NPI: 1255312831
Provider Name (Legal Business Name): CLOVERLEAF ENTERPRISE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 W WILSON ST
BANNING CA
92220-3042
US

IV. Provider business mailing address

5800 W WILSON ST
BANNING CA
92220-3042
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-1606
  • Fax: 951-845-4152
Mailing address:
  • Phone: 951-845-1606
  • Fax: 951-845-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number250000298
License Number StateCA

VIII. Authorized Official

Name: MR. ANTHONY ALBERT LOPEZ
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 951-845-1606