Provider Demographics
NPI:1053698134
Name:CHARTER HEALTHCARE OF RANCHO CUCAMONGA, LLC
Entity type:Organization
Organization Name:CHARTER HEALTHCARE OF RANCHO CUCAMONGA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAL
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:866-669-1686
Mailing Address - Street 1:9229 UTICA AVE., SUITE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4063
Mailing Address - Country:US
Mailing Address - Phone:866-669-1686
Mailing Address - Fax:909-532-8685
Practice Address - Street 1:9229 UTICA AVE., SUITE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4063
Practice Address - Country:US
Practice Address - Phone:866-669-1686
Practice Address - Fax:909-532-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550001908OtherDEPARTMENT OF PUBLIC HEALTH