Healthcare Provider Details

I. General information

NPI: 1548347354
Provider Name (Legal Business Name): MONTE VISTA GROVE HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2889 SAN PASQUAL ST
PASADENA CA
91107-5364
US

IV. Provider business mailing address

2889 SAN PASQUAL ST
PASADENA CA
91107-5364
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-6135
  • Fax: 626-796-9753
Mailing address:
  • Phone: 626-796-6135
  • Fax: 626-796-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970000086
License Number StateCA

VIII. Authorized Official

Name: MS. KIM P. HOUSER
Title or Position: CONTROLLER
Credential:
Phone: 626-796-6135