Healthcare Provider Details

I. General information

NPI: 1629857065
Provider Name (Legal Business Name): LA QUINTA CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78740 SANITA DR
LA QUINTA CA
92253-6807
US

IV. Provider business mailing address

78740 SANITA DR
LA QUINTA CA
92253-6807
US

V. Phone/Fax

Practice location:
  • Phone: 661-810-7293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: LACY FADDOUL
Title or Position: CEO
Credential:
Phone: 661-810-7293