Provider Demographics
NPI:1821095647
Name:KNOLLS CONVALESCENT HOSPITAL INC
Entity Type:Organization
Organization Name:KNOLLS CONVALESCENT HOSPITAL INC
Other - Org Name:DESERT KNOLLS CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-245-5361
Mailing Address - Street 1:16890 GREEN TREE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5618
Mailing Address - Country:US
Mailing Address - Phone:760-245-5361
Mailing Address - Fax:760-245-6247
Practice Address - Street 1:14973 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3923
Practice Address - Country:US
Practice Address - Phone:760-245-6477
Practice Address - Fax:760-245-6247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05076FMedicaid
CA055076Medicare ID - Type Unspecified