Healthcare Provider Details

I. General information

NPI: 1386629889
Provider Name (Legal Business Name): VILLA CONVALESCENT HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8965 MAGNOLIA AVE
RIVERSIDE CA
92503-4432
US

IV. Provider business mailing address

25910 ACERO STE 350
MISSION VIEJO CA
92691-7908
US

V. Phone/Fax

Practice location:
  • Phone: 951-689-5788
  • Fax:
Mailing address:
  • Phone: 949-441-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number250000219
License Number StateCA

VIII. Authorized Official

Name: MARC JOHNSON
Title or Position: CFO
Credential:
Phone: 949-373-8373