Provider Demographics
NPI:1104851716
Name:SOUTH COAST HEALTH & WELLNESS CORPORATION
Entity Type:Organization
Organization Name:SOUTH COAST HEALTH & WELLNESS CORPORATION
Other - Org Name:COMMUNITY CARE ON PALM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:JUMONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-686-9001
Mailing Address - Street 1:4768 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4012
Mailing Address - Country:US
Mailing Address - Phone:951-686-9001
Mailing Address - Fax:951-686-0148
Practice Address - Street 1:4768 PALM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4012
Practice Address - Country:US
Practice Address - Phone:951-686-9001
Practice Address - Fax:951-686-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250000115314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55711HMedicaid
CA5729700001Medicare NSC
CA555711Medicare Oscar/Certification