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General NPI Number Information
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NPI Number | 1790971117
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Entity Type | Organization
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Legal Business Name | EDGEMOOR
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 9065 EDGEMOOR DR
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City | SANTEE
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State | CA
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Zip | 92071-3037
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Country | US
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Telephone | 619-956-2855
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Fax | 619-956-2981
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Provider Business Mailing Address
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Address Line | 9065 EDGEMOOR DR
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City | SANTEE
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State | CA
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Zip | 92071-3037
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Country | US
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Telephone | 619-956-2855
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Fax | 619-956-2981
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Authorized Official
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Title or Position | RN/NURSE SUPERVISOR
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Name | MRS. COLEEN KAY WILSON
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Credential |
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Telephone | 619-956-2855
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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 | 452469
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License Number State | CA
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