Healthcare Provider Details

I. General information

NPI: 1811808447
Provider Name (Legal Business Name): MONTELAGO MOUNTAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7528 HAYSTACK LOOP
RIVERSIDE CA
92507-9601
US

IV. Provider business mailing address

7528 HAYSTACK LOOP
RIVERSIDE CA
92507-9601
US

V. Phone/Fax

Practice location:
  • Phone: 909-992-1080
  • Fax: 909-992-1080
Mailing address:
  • Phone:
  • Fax:

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: SYLVIE BOAL
Title or Position: COMPLIANCE
Credential:
Phone: 909-992-1080