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General NPI Number Information
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NPI Number | 1639992266
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Entity Type | Organization
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Legal Business Name | COBBLE CREEK CONGREGATE LIVING LLC
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Dates
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Enumeration Date | 11/04/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 7462 COBBLE CREEK DR
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City | EASTVALE
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State | CA
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Zip | 92880-3183
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Country | US
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Telephone | 949-922-7713
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Fax |
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Provider Business Mailing Address
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Address Line | 12672 LIMONITE AVE STE 3E-123
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City | EASTVALE
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State | CA
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Zip | 92880-4201
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Country | US
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Telephone | 949-922-7713
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MARC TANG
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Credential | ADMINISTRATOR
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Telephone | 949-235-6269
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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 |
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License Number State |
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