Basic Information
| Provider Information | |||||||||
| NPI: | 1114542198 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANTIOCH DUNES HEALTHCARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 N UNION AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014479829 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1210 A ST | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945092327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257578787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8014479829 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.