Provider Demographics
NPI:1255325056
Name:LONE PINE HEALTH CARE LLC
Entity type:Organization
Organization Name:LONE PINE HEALTH CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-347-0750
Mailing Address - Street 1:PO BOX 10487
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0487
Mailing Address - Country:US
Mailing Address - Phone:909-885-0268
Mailing Address - Fax:909-884-1722
Practice Address - Street 1:82262 VALENCIA AVE
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3120
Practice Address - Country:US
Practice Address - Phone:760-347-6000
Practice Address - Fax:760-755-6828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
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
CAZZT05278JMedicaid
CAZZT05278JMedicaid