Healthcare Provider Details

I. General information

NPI: 1144885922
Provider Name (Legal Business Name): MISSION INN SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 LEMON ST
RIVERSIDE CA
92501-2861
US

IV. Provider business mailing address

3401 LEMON ST
RIVERSIDE CA
92501-2861
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8202
  • Fax: 951-784-1508
Mailing address:
  • Phone: 951-686-8202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: LEE JOHNSON
Title or Position: TREASURER
Credential:
Phone: 208-401-1369