Healthcare Provider Details

I. General information

NPI: 1174921050
Provider Name (Legal Business Name): LANTERN OF CRESCENT CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 S STONINGTON RD
LAGUNA BEACH CA
92651-6741
US

IV. Provider business mailing address

4 S STONINGTON RD
LAGUNA BEACH CA
92651-6741
US

V. Phone/Fax

Practice location:
  • Phone: 949-445-1000
  • Fax:
Mailing address:
  • Phone: 949-445-1000
  • Fax:

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: SPENCER ROBERT SAMUELIAN
Title or Position: MANAGER
Credential:
Phone: 949-445-1000