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General NPI Number Information
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NPI Number | 1316080260
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Entity Type | Organization
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Legal Business Name | BROADWATER ONTARIO CARE CENTER, LLC
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 06/09/2008
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Provider Practice Location Address
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Address Line | 1661 S EUCLID AVE
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City | ONTARIO
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State | CA
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Zip | 91762-5826
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Country | US
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Telephone | 909-984-6713
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Fax | 909-984-5254
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Provider Business Mailing Address
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Address Line | 1661 S EUCLID AVE
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City | ONTARIO
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State | CA
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Zip | 91762-5826
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Country | US
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Telephone | 909-984-6713
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Fax | 909-984-5254
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Authorized Official
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Title or Position | MANAGER
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Name | DOUGLAS EASTON
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Credential |
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Telephone | 818-368-1862
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 240000181
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License Number State | CA
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