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General NPI Number Information
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NPI Number | 1710395777
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Entity Type | Organization
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Legal Business Name | EAGLE GLEN CARE HOME LLC
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Dates
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Enumeration Date | 07/23/2014
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Last Update Date | 07/23/2014
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Provider Practice Location Address
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Address Line | 1697 HONORS CIR
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City | CORONA
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State | CA
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Zip | 92883-0757
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Country | US
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Telephone | 951-582-9230
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Fax | 951-340-2740
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Provider Business Mailing Address
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Address Line | 1697 HONORS CIR
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City | CORONA
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State | CA
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Zip | 92883-0757
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Country | US
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Telephone | 951-582-9230
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Fax | 951-340-2740
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Authorized Official
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Title or Position | LICENSEE
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Name | RESTITUTO CALILUNG
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Credential |
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Telephone | 714-906-6046
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 336426012
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License Number State | CA
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