Healthcare Provider Details

I. General information

NPI: 1346798105
Provider Name (Legal Business Name): THE MONTEREY TRELLIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8914 TROY ST
SPRING VALLEY CA
91977-2609
US

IV. Provider business mailing address

8914 TROY ST.
SPRING VALLEY CA
91977
US

V. Phone/Fax

Practice location:
  • Phone: 619-697-4656
  • Fax:
Mailing address:
  • Phone: 619-697-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number374601400
License Number StateCA

VIII. Authorized Official

Name: MR. RODNEY P MICHEL
Title or Position: OWNER
Credential:
Phone: 619-846-0730