Provider Demographics
NPI:1811395353
Name:GRANDCARE SAN DIEGO LLC
Entity Type:Organization
Organization Name:GRANDCARE SAN DIEGO LLC
Other - Org Name:GRANDCARE SAN DIEGO LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-244-8446
Mailing Address - Street 1:3452 E FOOTHILL BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-6006
Mailing Address - Country:US
Mailing Address - Phone:866-554-2447
Mailing Address - Fax:
Practice Address - Street 1:2535 CAMINO DEL RIO S STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3764
Practice Address - Country:US
Practice Address - Phone:619-220-6980
Practice Address - Fax:619-220-6981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058345Medicaid