Basic Information
Provider Information | |||||||||
NPI: | 1205914579 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEMET VALLEY HEALTHCARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VALLEY HEALTH SYSTEM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1117 E DEVONSHIRE AVE | ||||||||
Address2: |   | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 92543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516522811 | ||||||||
FaxNumber: | 9519256323 | ||||||||
Practice Location | |||||||||
Address1: | 371 N WESTON AVE | ||||||||
Address2: |   | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 92543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516522811 | ||||||||
FaxNumber: | 9519256323 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARKO | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CFO INTERIM CEO | ||||||||
AuthorizedOfficialTelephone: | 9517666472 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X |   | CA | X |   | Nursing & Custodial Care Facilities | Custodial Care Facility |   | 314000000X |   | CA | X |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | LTC55623F | 01 | CA | MEDICAL | OTHER |