Provider Demographics
NPI:1770768509
Name:GHC OF UPLAND SNF, LLC
Entity type:Organization
Organization Name:GHC OF UPLAND SNF, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AR SYSTEMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-315-0984
Mailing Address - Street 1:275 GARNET WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5932
Mailing Address - Country:US
Mailing Address - Phone:909-949-4887
Mailing Address - Fax:909-949-8761
Practice Address - Street 1:275 GARNET WAY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5932
Practice Address - Country:US
Practice Address - Phone:909-949-4887
Practice Address - Fax:909-949-8761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000465314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55514FMedicaid
CA5974990001Medicare NSC
CA555514Medicare Oscar/Certification