Healthcare Provider Details

I. General information

NPI: 1255340592
Provider Name (Legal Business Name): CRESTVIEW CONVALESCENT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 S RIVERSIDE AVE
RIALTO CA
92376-7703
US

IV. Provider business mailing address

1471 S RIVERSIDE AVE
RIALTO CA
92376-7703
US

V. Phone/Fax

Practice location:
  • Phone: 909-877-0854
  • Fax:
Mailing address:
  • Phone: 909-877-0854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number240000134
License Number StateCA

VIII. Authorized Official

Name: ROY V BERGLUND
Title or Position: OWNER
Credential: MD
Phone: 909-877-1361