Provider Demographics
NPI:1508192790
Name:MOUNTAIN NURSING CARE SERVICES
Entity Type:Organization
Organization Name:MOUNTAIN NURSING CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-338-0448
Mailing Address - Street 1:PO BOX 4119
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-4119
Mailing Address - Country:US
Mailing Address - Phone:909-338-0448
Mailing Address - Fax:
Practice Address - Street 1:23493 CREST FOREST DR
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325-4119
Practice Address - Country:US
Practice Address - Phone:909-338-0448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000663251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5504240Medicaid