Provider Demographics
NPI:1891280012
Name:MOUNT MEGIDDO LLC
Entity Type:Organization
Organization Name:MOUNT MEGIDDO LLC
Other - Org Name:BANNING HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-849-4723
Mailing Address - Street 1:2368 TORRANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2500
Mailing Address - Country:US
Mailing Address - Phone:310-561-0231
Mailing Address - Fax:
Practice Address - Street 1:3476 W WILSON ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3420
Practice Address - Country:US
Practice Address - Phone:951-849-4723
Practice Address - Fax:951-755-8857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250000153314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA250000153OtherSTATE LICENSE