Healthcare Provider Details

I. General information

NPI: 1578758579
Provider Name (Legal Business Name): EDGEMOOR HOSPITAL/DPSNF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 12/29/2009
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: 619-596-5501
Mailing address:
  • Phone: 619-596-5500
  • Fax: 619-596-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number090000092
License Number StateCA

VIII. Authorized Official

Name: GWENMARIE HILLEARY
Title or Position: ADMINISTRATOR
Credential:
Phone: 619-596-5500