Healthcare Provider Details

I. General information

NPI: 1518175231
Provider Name (Legal Business Name): GROSSMONT IPG LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 MARENGO AVE
LA MESA CA
91942-2408
US

IV. Provider business mailing address

9619 CHESAPEAKE DR STE 103
SAN DIEGO CA
92123-1394
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-0281
  • Fax: 619-461-7736
Mailing address:
  • Phone: 858-565-4424
  • Fax: 858-565-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0800000337
License Number StateCA

VIII. Authorized Official

Name: DEBORAH MURPHY
Title or Position: CONTROLLER
Credential:
Phone: 858-565-4424