Basic Information
| Provider Information | |||||||||
| NPI: | 1184607418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHARP VILLA CORONADO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8695 SPECTRUM CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584993027 | ||||||||
| FaxNumber: | 8584993020 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 PROSPECT PL | ||||||||
| Address2: | |||||||||
| City: | CORONADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921181967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195223700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6195223700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 090000036 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC70017F | 05 | CA | MEDICAID |