MEDICARE: PRIMARY RELIANCE INC

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	3104A0625X	Assisted Living Facility (Mental Illness)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LTC60598F	OTHER	CA	ENCINAS PROVIDER NO.

General Provider Information

NPI Number	:	1205950714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY RELIANCE INC

Provider Business Mailing Address
First Line	:	226 N STEPHORA AVE
Second Line	:
City	:	COVINA
State	:	CA
Zip	:	91724-3152
Country	:	US
Telephone Number	:	626-966-1373
Fax Number	:	626-915-1155

Provider Business Practice Location Address
First Line	:	1342 PASEO ENCINAS
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-4217
Country	:	US
Telephone Number	:	909-599-4396
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CELESTINE GREEN
Credential	:
Telephone Number	:	626-966-1373

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	08/22/2020

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Directions to “PRIMARY RELIANCE INC ” Practice Location

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