Provider Demographics
NPI:1386657054
Name:CLOISTERS OF LA JOLLA INC
Entity type:Organization
Organization Name:CLOISTERS OF LA JOLLA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL COUNSEL
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:6194418771
Authorized Official - Phone:619-441-8771
Mailing Address - Street 1:7160 FAY AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5511
Mailing Address - Country:US
Mailing Address - Phone:858-459-4361
Mailing Address - Fax:858-459-1386
Practice Address - Street 1:7160 FAY AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5511
Practice Address - Country:US
Practice Address - Phone:858-459-4361
Practice Address - Fax:858-459-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000031314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2039040Medicaid
CA555545Medicare ID - Type Unspecified