Healthcare Provider Details

I. General information

NPI: 1689077588
Provider Name (Legal Business Name): MISSION TRAILS HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8787 CENTER DR
LA MESA CA
91942-3034
US

IV. Provider business mailing address

8787 CENTER DR
LA MESA CA
91942-3034
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-4444
  • Fax: 619-460-6341
Mailing address:
  • Phone: 619-460-4444
  • Fax: 619-460-6341

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: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249