=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235133687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GHC OF NATIONAL CITY I, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 08/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 SOUTH EUCLID AVE
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-791-7700
-----------------------------------------------------
Fax | 619-791-7791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 902 SOUTH EUCLID AVE
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-791-7700
-----------------------------------------------------
Fax | 619-791-7791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | LOIS MASTROCOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-241-5600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 090000049
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------