Provider Demographics
NPI:1689077588
Name:MISSION TRAILS HEALTHCARE LLC
Entity Type:Organization
Organization Name:MISSION TRAILS HEALTHCARE LLC
Other - Org Name:GROSSMONT POST ACUTE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:8787 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3034
Mailing Address - Country:US
Mailing Address - Phone:619-460-4444
Mailing Address - Fax:619-460-6341
Practice Address - Street 1:8787 CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3034
Practice Address - Country:US
Practice Address - Phone:619-460-4444
Practice Address - Fax:619-460-6341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2023-09-07
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
CA055632Medicare Oscar/Certification