Healthcare Provider Details

I. General information

NPI: 1508565987
Provider Name (Legal Business Name): 1030 WARNER AVENUE I OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 W WARNER AVE
SANTA ANA CA
92707-3147
US

IV. Provider business mailing address

1030 W WARNER AVE
SANTA ANA CA
92707-3147
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-6450
  • Fax:
Mailing address:
  • Phone: 714-546-6450
  • Fax: 714-546-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAMELA D SHAW
Title or Position: SVP RCM
Credential:
Phone: 760-445-0699