Provider Demographics
NPI:1194685263
Name:MINONA GARDEN LLC
Entity type:Organization
Organization Name:MINONA GARDEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUNGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-285-7878
Mailing Address - Street 1:22854 MINONA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5162
Mailing Address - Country:US
Mailing Address - Phone:909-285-7878
Mailing Address - Fax:
Practice Address - Street 1:22854 MINONA DR
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5162
Practice Address - Country:US
Practice Address - Phone:909-285-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA310400000XMedicaid