Provider Demographics
NPI:1598746182
Name:DAVID KLEIS II, LLC
Entity Type:Organization
Organization Name:DAVID KLEIS II, LLC
Other - Org Name:PALM GROVE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MAE
Authorized Official - Middle Name:T
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-845-3125
Mailing Address - Street 1:1665 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-2512
Mailing Address - Country:US
Mailing Address - Phone:951-845-3125
Mailing Address - Fax:951-769-1582
Practice Address - Street 1:1665 E 8TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-2512
Practice Address - Country:US
Practice Address - Phone:951-845-3125
Practice Address - Fax:951-769-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55740GMedicaid
CA55-5740Medicare ID - Type Unspecified