Basic Information
| Provider Information | |||||||||
| NPI: | 1912094418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEMET VALLEY MEDICAL CENTER SUBACUTE UNIT | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | A CALIFORNIA LOCAL HEALTHCARE DISTRICT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1117 E DEVONSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516522811 | ||||||||
| FaxNumber: | 9519256323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 E DEVONSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516522811 | ||||||||
| FaxNumber: | 9519256323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARKO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 9517666472 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | CA | X | Nursing & Custodial Care Facilities | Custodial Care Facility | 314000000X | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC70082F | 01 | CA | MEDICAL | OTHER |