Provider Demographics
NPI:1114096120
Name:FONTANA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:FONTANA HEALTHCARE, LLC
Other - Org Name:CASA MARIA HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-494-1233
Mailing Address - Street 1:250 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2456
Mailing Address - Country:US
Mailing Address - Phone:805-494-1233
Mailing Address - Fax:805-494-1411
Practice Address - Street 1:17933 SAN BERNARDINO AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6151
Practice Address - Country:US
Practice Address - Phone:909-877-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
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