Healthcare Provider Details

I. General information

NPI: 1356120307
Provider Name (Legal Business Name): MONTELAGO CONGREGATE LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12537 POINSETTA DR
RIVERSIDE CA
92503-7067
US

IV. Provider business mailing address

20816 CENTER STREET
RIVERSIDE CA
92507
US

V. Phone/Fax

Practice location:
  • Phone: 909-643-1009
  • Fax: 951-643-1031
Mailing address:
  • Phone: 909-643-1009
  • Fax: 951-643-1031

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: MR. EARL BONNER
Title or Position: ADMINISTRATOR
Credential: RRT/RCT
Phone: 951-662-0719