Healthcare Provider Details

I. General information

NPI: 1114096120
Provider Name (Legal Business Name): FONTANA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17933 SAN BERNARDINO AVE
FONTANA CA
92335-6151
US

IV. Provider business mailing address

250 FAIRVIEW RD
THOUSAND OAKS CA
91361-2456
US

V. Phone/Fax

Practice location:
  • Phone: 909-877-1555
  • Fax:
Mailing address:
  • Phone: 805-494-1233
  • Fax: 805-494-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. JEOUNG LEE
Title or Position: PRESIDENT CEO
Credential:
Phone: 805-494-1233