Healthcare Provider Details

I. General information

NPI: 1770884868
Provider Name (Legal Business Name): 9025 COLORADO AVENUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 COLORADO AVE
RIVERSIDE CA
92503-2157
US

IV. Provider business mailing address

9025 COLORADO AVE
RIVERSIDE CA
92503-2157
US

V. Phone/Fax

Practice location:
  • Phone: 951-688-3636
  • Fax:
Mailing address:
  • Phone: 951-688-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. FRANK MORITZ
Title or Position: CONTROLLER
Credential:
Phone: 323-363-3170