Basic Information
| Provider Information | |||||||||
| NPI: | 1073902672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POMERADO OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BOULDER CREEK POST ACUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 PACIFICA | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584876242 | ||||||||
| FaxNumber: | 8584874282 | ||||||||
| Practice Location | |||||||||
| Address1: | 12696 MONTE VISTA RD | ||||||||
| Address2: | |||||||||
| City: | POWAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920642500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584876242 | ||||||||
| FaxNumber: | 8584874282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2015 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | LELEAND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9492202000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.