Healthcare Provider Details

I. General information

NPI: 1003098906
Provider Name (Legal Business Name): LIFEHOUSE SAN DIEGO OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 MEADOW LARK DR
SAN DIEGO CA
92123-2710
US

IV. Provider business mailing address

1000 CORPORATE POINTE SUITE 100
CULVER CITY CA
90230-7690
US

V. Phone/Fax

Practice location:
  • Phone: 858-277-6460
  • Fax:
Mailing address:
  • Phone: 310-337-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TRACY CLARK
Title or Position: CEO
Credential:
Phone: 310-337-1929