Healthcare Provider Details

I. General information

NPI: 1457345001
Provider Name (Legal Business Name): AG LA MESA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5696 LAKE MURRAY BOULEVARD
LA MESA CA
91942
US

IV. Provider business mailing address

5696 LAKE MURRAY BOULEVARD
LA MESA CA
91942
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-7871
  • Fax: 619-460-4810
Mailing address:
  • Phone: 619-460-7871
  • Fax: 310-574-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number080000020
License Number StateCA

VIII. Authorized Official

Name: MR. JACOB WINTNER
Title or Position: MANAGER
Credential:
Phone: 323-651-1808