Healthcare Provider Details

I. General information

NPI: 1427129253
Provider Name (Legal Business Name): STEPHEN R CARTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12436 ROYAL RD
EL CAJON CA
92021-1723
US

IV. Provider business mailing address

PO BOX 2427
EL CAJON CA
92021-0427
US

V. Phone/Fax

Practice location:
  • Phone: 619-443-3886
  • Fax:
Mailing address:
  • Phone: 619-443-3886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number080000090
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN RANDALL CARTER
Title or Position: NHA OWNER
Credential: NURSING HOME ADMINIS
Phone: 619-277-4350