Healthcare Provider Details

I. General information

NPI: 1003198342
Provider Name (Legal Business Name): LA JOLLA SKILLED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3884 NOBEL DRIVE
SAN DIEGO CA
92122-5700
US

IV. Provider business mailing address

3884 NOBEL DRIVE
SAN DIEGO CA
92122-5700
US

V. Phone/Fax

Practice location:
  • Phone: 858-625-8700
  • Fax: 858-625-8777
Mailing address:
  • Phone: 858-625-8700
  • Fax: 858-625-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249