Healthcare Provider Details

I. General information

NPI: 1003001199
Provider Name (Legal Business Name): EDGEMOOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9065 EDGEMOOR DRIVE EDGEMOOR HOSPITAL
SANTEE CA
92071-3037
US

IV. Provider business mailing address

9065 EDGEMOOR DR
SANTEE CA
92071-3037
US

V. Phone/Fax

Practice location:
  • Phone: 619-956-2978
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number461705
License Number StateCA

VIII. Authorized Official

Name: MRS. MYRNA CORPUZ ALMUETE
Title or Position: RN
Credential:
Phone: 619-956-2978