Healthcare Provider Details

I. General information

NPI: 1811805047
Provider Name (Legal Business Name): LEGACY OF LOVE RESIDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6819 SUNRIDGE CT
FONTANA CA
92336-1420
US

IV. Provider business mailing address

6819 SUNRIDGE CT
FONTANA CA
92336-1420
US

V. Phone/Fax

Practice location:
  • Phone: 909-833-1077
  • Fax:
Mailing address:
  • Phone: 909-833-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: ISABELLE R WILCOX
Title or Position: OWNER /ADMINSTRATOR/ DON
Credential: FNP-C
Phone: 909-833-1077