Provider Demographics
NPI:1720072374
Name:AG LAGUNA HILLS, LLC
Entity type:Organization
Organization Name:AG LAGUNA HILLS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-651-1808
Mailing Address - Street 1:24452 HEALTH CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-837-8000
Mailing Address - Fax:310-574-1322
Practice Address - Street 1:24452 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-837-8000
Practice Address - Fax:949-837-5187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000084314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT06110IMedicaid
CAZZT06110IMedicaid
CAZZT06110IMedicaid