Healthcare Provider Details

I. General information

NPI: 1437338217
Provider Name (Legal Business Name): INNOVATIVE LAKE FOREST OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23442 EL TORO RD
LAKE FOREST CA
92630-6979
US

IV. Provider business mailing address

1282 PACIFIC OAKS PL
ESCONDIDO CA
92029-2900
US

V. Phone/Fax

Practice location:
  • Phone: 800-584-8084
  • Fax:
Mailing address:
  • Phone: 760-690-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NICK DOBRON
Title or Position: VICE PRESIDENT
Credential:
Phone: 760-690-5262