Provider Demographics
NPI:1356322937
Name:CLOVERLEAF ENTERPRISES, INC.
Entity type:Organization
Organization Name:CLOVERLEAF ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:I
Authorized Official - Last Name:BERTUMEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:NHA
Authorized Official - Phone:951-849-4723
Mailing Address - Street 1:3476 W WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3420
Mailing Address - Country:US
Mailing Address - Phone:951-849-4723
Mailing Address - Fax:951-849-0972
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:951-849-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
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
CALTC55319GMedicaid
CALTC55319GMedicaid