Provider Demographics
NPI:1568659977
Name:POWAY ADULT DAY HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:POWAY ADULT DAY HEALTH CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MA
Authorized Official - Phone:858-748-5044
Mailing Address - Street 1:10923 CAMINITO TIERRA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3569
Mailing Address - Country:US
Mailing Address - Phone:858-748-5044
Mailing Address - Fax:858-748-5405
Practice Address - Street 1:13180 POWAY RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-4612
Practice Address - Country:US
Practice Address - Phone:858-748-5044
Practice Address - Fax:858-748-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-29
Last Update Date:2007-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70301FMedicaid