Provider Demographics
NPI:1184014680
Name:MELON HOLDINGS LLC
Entity Type:Organization
Organization Name:MELON HOLDINGS LLC
Other - Org Name:MARYSVILLE POST-ACUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-471-0388
Mailing Address - Street 1:100 E SAN MARCOS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2986
Mailing Address - Country:US
Mailing Address - Phone:760-471-0388
Mailing Address - Fax:
Practice Address - Street 1:1617 RAMIREZ ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-4334
Practice Address - Country:US
Practice Address - Phone:530-742-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555682OtherPTAN
CA1184014680Medicaid