Healthcare Provider Details

I. General information

NPI: 1336134204
Provider Name (Legal Business Name): LEMON GROVE HEALTH ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8351 BROADWAY
LEMON GROVE CA
91945-2009
US

IV. Provider business mailing address

8351 BROADWAY
LEMON GROVE CA
91945-2009
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-0294
  • Fax: 619-461-1064
Mailing address:
  • Phone: 619-463-0294
  • Fax: 619-461-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number090000067
License Number StateCA

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249