Healthcare Provider Details

I. General information

NPI: 1518942143
Provider Name (Legal Business Name): CALIFORNIAN MAGNOLIA CONVALESCENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8133 MAGNOLIA AVE
RIVERSIDE CA
92504-3409
US

IV. Provider business mailing address

8133 MAGNOLIA AVE
RIVERSIDE CA
92504-3409
US

V. Phone/Fax

Practice location:
  • Phone: 951-688-4321
  • Fax: 951-352-2768
Mailing address:
  • Phone: 951-688-4321
  • Fax: 951-352-2768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number250000170
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number250000170
License Number StateCA

VIII. Authorized Official

Name: MRS. KIMBERLY SUE RICHARDS
Title or Position: ADMINSTRATOR
Credential: LIC NURSING HOME ADM
Phone: 951-688-4321