Healthcare Provider Details

I. General information

NPI: 1104382183
Provider Name (Legal Business Name): KAMALI'I FOSTER FAMILY AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31772 CASINO DR STE B
LAKE ELSINORE CA
92530-4502
US

IV. Provider business mailing address

31772 CASINO DR STE B
LAKE ELSINORE CA
92530-4502
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-9400
  • Fax: 951-674-9486
Mailing address:
  • Phone: 951-674-9400
  • Fax: 951-674-9486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOHN ERIC MORTENSEN
Title or Position: CEO/PROGRAM DIRECTOR
Credential: M.S.
Phone: 951-674-9400