Healthcare Provider Details

I. General information

NPI: 1790971117
Provider Name (Legal Business Name): EDGEMOOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9065 EDGEMOOR DR
SANTEE CA
92071-3037
US

IV. Provider business mailing address

9065 EDGEMOOR DR
SANTEE CA
92071-3037
US

V. Phone/Fax

Practice location:
  • Phone: 619-956-2855
  • Fax: 619-956-2981
Mailing address:
  • Phone: 619-956-2855
  • Fax: 619-956-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number452469
License Number StateCA

VIII. Authorized Official

Name: MRS. COLEEN KAY WILSON
Title or Position: RN/NURSE SUPERVISOR
Credential:
Phone: 619-956-2855