Healthcare Provider Details

I. General information

NPI: 1750447140
Provider Name (Legal Business Name): SUNSET HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 GARNET WAY
UPLAND CA
91786-5932
US

IV. Provider business mailing address

275 GARNET WAY
UPLAND CA
91786-5932
US

V. Phone/Fax

Practice location:
  • Phone: 909-949-4887
  • Fax:
Mailing address:
  • Phone: 909-949-4887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number240000465
License Number StateCA

VIII. Authorized Official

Name: LOIS MASTROCOLA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 714-241-5600