Healthcare Provider Details

I. General information

NPI: 1790779288
Provider Name (Legal Business Name): AG REDLANDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 EAST HIGHLAND AVENUE
REDLANDS CA
92374
US

IV. Provider business mailing address

700 EAST HIGHLAND AVENUE
REDLANDS CA
92374
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-2678
  • Fax: 909-307-9768
Mailing address:
  • Phone: 909-793-2678
  • Fax: 310-574-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number240000114
License Number StateCA

VIII. Authorized Official

Name: MR. JACOB WINTNER
Title or Position: MANAGER
Credential:
Phone: 323-651-1808