Healthcare Provider Details

I. General information

NPI: 1891280012
Provider Name (Legal Business Name): MOUNT MEGIDDO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 06/29/2018
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

2368 TORRANCE BLVD
TORRANCE CA
90501-2500
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-4723
  • Fax: 951-755-8857
Mailing address:
  • Phone: 310-561-0231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number250000153
License Number StateCA

VIII. Authorized Official

Name: ELENITA PEREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-849-4723