Healthcare Provider Details

I. General information

NPI: 1013953199
Provider Name (Legal Business Name): KOA HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1391 E MADISON AVE
EL CAJON CA
92021-8568
US

IV. Provider business mailing address

262 N UNIVERSITY AVE
FARMINGTON UT
84025-2975
US

V. Phone/Fax

Practice location:
  • Phone: 619-444-1107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number090000071
License Number StateCA

VIII. Authorized Official

Name: JOHN MITCHELL
Title or Position: SECRETARY
Credential:
Phone: 385-988-3319