MEDICARE: PACIFICA SL PENASQUITOS LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311500000X	Alzheimer Center (Dementia Center)
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1053163790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFICA SL PENASQUITOS LP

Provider Business Mailing Address
First Line	:	12979 RANCHO PENASQUITOS BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-2922
Country	:	US
Telephone Number	:	858-538-0802
Fax Number	:

Provider Business Practice Location Address
First Line	:	12979 RANCHO PENASQUITOS BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-2922
Country	:	US
Telephone Number	:	858-538-0802
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	DEEPAK ISRANI
Credential	:
Telephone Number	:	619-296-9000

Provider Enumeration Date	:	04/04/2024
Last Update Date	:	04/04/2024

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