Provider Demographics
NPI:1225049299
Name:CALIFORNIAN MAGNOLIA CONVALESCENT HOSPITAL INC.
Entity Type:Organization
Organization Name:CALIFORNIAN MAGNOLIA CONVALESCENT HOSPITAL INC.
Other - Org Name:MAGNOLIA HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTOLLER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-688-4321
Mailing Address - Street 1:8133 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-3498
Mailing Address - Country:US
Mailing Address - Phone:951-688-4321
Mailing Address - Fax:951-688-0258
Practice Address - Street 1:8133 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3498
Practice Address - Country:US
Practice Address - Phone:951-688-4321
Practice Address - Fax:951-688-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHPC01641FMedicaid
CAHPC01641FMedicaid