Healthcare Provider Details

I. General information

NPI: 1225049299
Provider Name (Legal Business Name): CALIFORNIAN MAGNOLIA CONVALESCENT HOSPITAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8133 MAGNOLIA AVE
RIVERSIDE CA
92504-3498
US

IV. Provider business mailing address

8133 MAGNOLIA AVE
RIVERSIDE CA
92504-3498
US

V. Phone/Fax

Practice location:
  • Phone: 951-688-4321
  • Fax: 951-688-0258
Mailing address:
  • Phone: 951-688-4321
  • Fax: 951-688-0258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number StateCA

VIII. Authorized Official

Name: GRANT EDGSON
Title or Position: CONTOLLER
Credential:
Phone: 951-688-4321