Provider Demographics
NPI:1063494276
Name:DAVID KLEIS III, LLC
Entity Type:Organization
Organization Name:DAVID KLEIS III, LLC
Other - Org Name:MIRAVILLA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MAE
Authorized Official - Middle Name:T
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-845-3184
Mailing Address - Street 1:9246 AVENIDA MIRAVILLA
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92223-3835
Mailing Address - Country:US
Mailing Address - Phone:951-845-3194
Mailing Address - Fax:951-845-2064
Practice Address - Street 1:9246 AVENIDA MIRAVILLA
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92223-3835
Practice Address - Country:US
Practice Address - Phone:951-845-3194
Practice Address - Fax:951-845-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05754GMedicaid
CA55-5492Medicare ID - Type Unspecified