Healthcare Provider Details

I. General information

NPI: 1477298107
Provider Name (Legal Business Name): 551 GIBSON AVE SNF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 GIBSON AVE
PACIFIC GROVE CA
93950-4330
US

IV. Provider business mailing address

4747 VIEWRIDGE AVE STE 105
SAN DIEGO CA
92123-1688
US

V. Phone/Fax

Practice location:
  • Phone: 831-657-5200
  • Fax:
Mailing address:
  • Phone: 619-402-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD MARTIN
Title or Position: MANAGER
Credential:
Phone: 831-657-5200