Healthcare Provider Details

I. General information

NPI: 1811972193
Provider Name (Legal Business Name): GRAND TERRACE HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5174
US

IV. Provider business mailing address

25910 ACERO STE 350
MISSION VIEJO CA
92691-7908
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-5221
  • Fax:
Mailing address:
  • Phone: 949-441-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number240000143
License Number StateCA

VIII. Authorized Official

Name: MARC JOHNSON
Title or Position: CFO
Credential:
Phone: 949-373-8373