Healthcare Provider Details

I. General information

NPI: 1760118962
Provider Name (Legal Business Name): INDIAN CANYON PACC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57333 JOSHUA LN
YUCCA VALLEY CA
92284-4124
US

IV. Provider business mailing address

57333 JOSHUA LN
YUCCA VALLEY CA
92284-4124
US

V. Phone/Fax

Practice location:
  • Phone: 760-853-4750
  • Fax:
Mailing address:
  • Phone: 951-977-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: STEVEN R POWELL
Title or Position: PRESIDENT/MEMBER
Credential:
Phone: 909-795-2421