MEDICARE: PACIFICA MONTE VISTA LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1609628130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFICA MONTE VISTA LLC

Provider Business Mailing Address
First Line	:	2211 MASSACHUSETTS AVE
Second Line	:
City	:	LEMON GROVE
State	:	CA
Zip	:	91945-3616
Country	:	US
Telephone Number	:	619-465-1331
Fax Number	:

Provider Business Practice Location Address
First Line	:	2211 MASSACHUSETTS AVE
Second Line	:
City	:	LEMON GROVE
State	:	CA
Zip	:	91945-3616
Country	:	US
Telephone Number	:	619-465-1331
Fax Number	:

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

Provider Enumeration Date	:	04/05/2024
Last Update Date	:	04/05/2024

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