Healthcare Provider Details

I. General information

NPI: 1609288133
Provider Name (Legal Business Name): MADDIGRL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 WANEK RD
ESCONDIDO CA
92027-2889
US

IV. Provider business mailing address

1248 ATWATER ST
CHULA VISTA CA
91913-1453
US

V. Phone/Fax

Practice location:
  • Phone: 760-781-1027
  • Fax: 888-588-0942
Mailing address:
  • Phone: 619-934-7884
  • Fax: 888-588-0942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number374603045
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number374603045
License Number StateCA

VIII. Authorized Official

Name: MR. TEOFILO POSADAS MENDOZA JR.
Title or Position: PRESIDENT
Credential:
Phone: 619-934-7884