Healthcare Provider Details

I. General information

NPI: 1396004867
Provider Name (Legal Business Name): EDGEMOOR HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 PARK CENTER DR
SANTEE CA
92071-6957
US

IV. Provider business mailing address

655 PARK CENTER DR
SANTEE CA
92071-6957
US

V. Phone/Fax

Practice location:
  • Phone: 619-596-5500
  • Fax:
Mailing address:
  • Phone: 619-596-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number263563
License Number StateCA

VIII. Authorized Official

Name: REBECCA BERKEY
Title or Position: HUMAN RESOURCES ASSISTANT
Credential:
Phone: 619-338-2342