MEDICARE: BALBOA HEALTHCARE, 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	314000000X	Skilled Nursing Facility	090000057	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	090000057	OTHER	CA	CDPH FACILITY LICENSE NUMBER

General Provider Information

NPI Number	:	1578521274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALBOA HEALTHCARE, INC.

Provider Business Mailing Address
First Line	:	262 N UNIVERSITY AVE
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-2975
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 4TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4913
Country	:	US
Telephone Number	:	619-291-5270
Fax Number	:	619-291-1671

Authorized Official
Title or Position	:	SECRETARY
Name	:	JOHN MITCHELL
Credential	:
Telephone Number	:	385-988-3319

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	08/19/2024

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