Provider Demographics
NPI:1437338217
Name:INNOVATIVE LAKE FOREST OPERATIONS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE LAKE FOREST OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DOBRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-690-5262
Mailing Address - Street 1:1282 PACIFIC OAKS PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-2900
Mailing Address - Country:US
Mailing Address - Phone:760-690-5262
Mailing Address - Fax:
Practice Address - Street 1:23442 EL TORO RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6979
Practice Address - Country:US
Practice Address - Phone:800-584-8084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility