Healthcare Provider Details

I. General information

NPI: 1285113845
Provider Name (Legal Business Name): EASTVALE CONGREGATE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6764 BLACK FOREST DR
EASTVALE CA
92880-3922
US

IV. Provider business mailing address

6764 BLACK FOREST DR
EASTVALE CA
92880-3922
US

V. Phone/Fax

Practice location:
  • Phone: 951-268-2150
  • Fax: 951-479-5260
Mailing address:
  • Phone: 951-268-2150
  • Fax: 951-479-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. LESLEY SIHAVONG VANNOY
Title or Position: CEO/ OWNER
Credential:
Phone: 951-847-5476