Provider Demographics
NPI:1215562913
Name:STATESIDE MEDICAL LLC
Entity Type:Organization
Organization Name:STATESIDE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:MICLAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-408-8996
Mailing Address - Street 1:1920 N INDIAN HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-2721
Mailing Address - Country:US
Mailing Address - Phone:714-408-8996
Mailing Address - Fax:
Practice Address - Street 1:380 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1751
Practice Address - Country:US
Practice Address - Phone:714-408-8996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility