Basic Information
Provider Information | |||||||||
NPI: | 1740664762 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KUMQUAT HOLDINGS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PRIMROSE POST-ACUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 E SAN MARCOS BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692986 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7604710388 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 515 CENTINELA AVE | ||||||||
Address2: |   | ||||||||
City: | INGLEWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 903023215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3106744500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2015 | ||||||||
LastUpdateDate: | 08/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TILFORD | ||||||||
AuthorizedOfficialFirstName: | TOBY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7604710388 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 910000024 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 1972721355 | 05 | CA |   | MEDICAID |