Provider Demographics
NPI:1932984788
Name:SKILLED SAN DIMAS LLC
Entity Type:Organization
Organization Name:SKILLED SAN DIMAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-201-5888
Mailing Address - Street 1:1817 AVENIDA DEL DIABLO
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-3112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1740 S SAN DIMAS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-5108
Practice Address - Country:US
Practice Address - Phone:909-394-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility