Provider Demographics
NPI:1225345614
Name:MIRAMONTE ENTERPRISES
Entity Type:Organization
Organization Name:MIRAMONTE ENTERPRISES
Other - Org Name:SAN JACINTO HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-782-1878
Mailing Address - Street 1:275 N SAN JACINTO ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4453
Mailing Address - Country:US
Mailing Address - Phone:951-658-9441
Mailing Address - Fax:951-766-1908
Practice Address - Street 1:275 N SAN JACINTO ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4453
Practice Address - Country:US
Practice Address - Phone:951-658-9441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANOT AVAILABLE314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05223LMedicaid
CA055223Medicare Oscar/Certification