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General NPI Number Information
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NPI Number | 1760969141
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Entity Type | Organization
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Legal Business Name | GRANDMOTHERS VILLAGE APC
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Dates
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Enumeration Date | 07/27/2018
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Last Update Date | 07/27/2018
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Provider Practice Location Address
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Address Line | 8469 LA MESA BLVD
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City | LA MESA
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State | CA
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Zip | 91942-5335
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Country | US
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Telephone | 619-466-8773
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Fax |
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Provider Business Mailing Address
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Address Line | 8469 LA MESA BLVD
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City | LA MESA
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State | CA
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Zip | 91942-5335
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DANIEL SANDERSON II
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Credential |
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Telephone | 619-466-8773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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