Healthcare Provider Details

I. General information

NPI: 1740871979
Provider Name (Legal Business Name): CASA PALMERA CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2021
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 LUSK BLVD
SAN DIEGO CA
92121
US

IV. Provider business mailing address

18401 VON KARMAN AVE STE 500
IRVINE CA
92612-8531
US

V. Phone/Fax

Practice location:
  • Phone: 714-828-1800
  • Fax: 714-882-1186
Mailing address:
  • Phone: 714-828-1800
  • Fax: 714-882-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MAGDALEN GUSTILO
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 714-568-7667