Shaded Arbor LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

374603523 Issued in CA

Legal business name

SHADED ARBOR LLC

Practice address

1412 Groveland Ter
El Cajon, CA 92021-3418

Phone

(619) 631-7000

Fax

(619) 631-7591

NPI assigned

Nov 20, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Richard Mutka

Title

Owner

Phone

(951) 961-7410

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1416441600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1416441600000",
    "number": "1003213950",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1412 GROVELAND TER",
            "city": "EL CAJON",
            "state": "CA",
            "postal_code": "920213418",
            "telephone_number": "619-631-7000",
            "fax_number": "619-631-7591"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1412 GROVELAND TER",
            "city": "EL CAJON",
            "state": "CA",
            "postal_code": "920213418",
            "telephone_number": "619-631-7000",
            "fax_number": "619-631-7591"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADED ARBOR LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-11-20",
        "last_updated": "2014-11-20",
        "status": "A",
        "authorized_official_last_name": "MUTKA",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "951-961-7410"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "CA",
            "license": "374603523",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in El Cajon, CA
• Providers in El Cajon, CA by specialty
• Assisted Living Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.