Provider Demographics
NPI:1518942143
Name:CALIFORNIAN MAGNOLIA CONVALESCENT
Entity Type:Organization
Organization Name:CALIFORNIAN MAGNOLIA CONVALESCENT
Other - Org Name:MAGNOLIA REHABILITATION AND NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LIC NURSING HOME ADM
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:92504-3409
Mailing Address - Country:US
Mailing Address - Phone:951-688-4321
Mailing Address - Fax:951-352-2768
Practice Address - Street 1:8133 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3409
Practice Address - Country:US
Practice Address - Phone:951-688-4321
Practice Address - Fax:951-352-2768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250000170314000000X, 315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05474FMedicaid
CA055474Medicare ID - Type Unspecified