Healthcare Provider Details

I. General information

NPI: 1356322937
Provider Name (Legal Business Name): CLOVERLEAF ENTERPRISES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3476 W WILSON ST
BANNING CA
92220-3420
US

IV. Provider business mailing address

3476 W WILSON ST
BANNING CA
92220-3420
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-4723
  • Fax: 951-849-0972
Mailing address:
  • Phone: 951-849-4723
  • Fax: 951-849-0972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARIO I BERTUMEN SR.
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 951-849-4723