Basic Information
Provider Information | |||||||||
NPI: | 1750486379 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RANCHO VISTA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RANCHO VISTA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9619 CHESAPEAKE DR | ||||||||
Address2: | SUITE 103 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921231368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585654424 | ||||||||
FaxNumber: | 8585652428 | ||||||||
Practice Location | |||||||||
Address1: | 760 E BOBIER DR | ||||||||
Address2: |   | ||||||||
City: | VISTA | ||||||||
State: | CA | ||||||||
PostalCode: | 920843806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609411480 | ||||||||
FaxNumber: | 7609415981 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARNARD | ||||||||
AuthorizedOfficialFirstName: | B. | ||||||||
AuthorizedOfficialMiddleName: | RENEE | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8585654424 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.