Healthcare Provider Details

I. General information

NPI: 1871546887
Provider Name (Legal Business Name): FOUNTAINS LA JOLLA SL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3884 NOBEL DR
SAN DIEGO CA
92122-5700
US

IV. Provider business mailing address

2020 W RUDASILL RD ATTN: MEDICARE BILLING
TUCSON AZ
85704-7800
US

V. Phone/Fax

Practice location:
  • Phone: 858-625-8700
  • Fax: 959-625-8777
Mailing address:
  • Phone: 520-797-4000
  • Fax: 520-797-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number080000401
License Number StateCA

VIII. Authorized Official

Name: GRETA FRUHLING FRAZIER
Title or Position: DIRECTOR
Credential:
Phone: 520-797-4000