NPIMap

Organization Active NPI

Koa Holdings, LLC

  • Skilled Nursing Facility
  • El Cajon, CA
National Provider Identifier
1013953199
Registry record updated Aug 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
090000071 Issued in CA
Legal business name
KOA HOLDINGS, LLC
Practice address
1391 E Madison Ave
El Cajon, CA 92021-8568
Phone
(619) 444-1107
NPI assigned
Jun 20, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 20, 2024

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

Authorized official

Name
John Mitchell
Title
Secretary
Phone
(385) 988-3319

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 090000071 CA Primary

Addresses

Primary practice location

1391 E Madison Ave
El Cajon, CA 92021-8568

Mailing address

262 N University Ave
Farmington, UT 84025-2975

Other identifiers 1

IdentifierTypeStateIssuer
ZZT05064IMedicaidCA

Other names 1

  • COTTONWOOD CANYON HEALTHCARE CENTER Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060127000033 CA Part A Provider - Skilled Nursing Facility 9436163698 Practice locations: El Cajon, CA

Skilled nursing facility certification: CCN 055064

Legal name
KOA HOLDINGS LLC
Doing business as
COTTONWOOD CANYON HEALTHCARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 1, 1967
Last certification
Dec 12, 2024
Beds
96
Ownership / control type
Corporation
Multi-facility organization
Providence Administrative Consulting
Most recent change of ownership
Mar 1, 2006
Organization structure
LLCProprietary
Incorporated
Dec 5, 2005 in CA
Enrollment address
1391 E Madison Ave
El Cajon, CA 92021-8568
Nursing home name
COTTONWOOD CANYON HEALTHCARE CENTER
Affiliated entity
PACS GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Cottonwood Canyon Healthcare CenterCCN 055064
Overall star rating
3 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Jan 1, 1967
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
9690.1 residents per day on average
Chain
Pacs Group274 facilities in the chain
Penalties (3 years)
1Fines totaling $9,110

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0898980Cottonwood Canyon Healthcare Center1391 E Madison Ave, El Cajon, CA 92021Certificate of waiverMar 15, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mansour Mofidi Individual Contracted Managing EmployeeMD; Oct 1, 2022
Jason H Murray Individual 5% Or Greater Indirect Ownership Interest Apr 15, 2024 41.8%
John T Mitchell Individual Corporate OfficerSecretary Jan 1, 2024
Hunter M Moore Individual W-2 Managing EmployeeAdministrator Aug 1, 2022
Operational/Managerial ControlAdministrator Aug 1, 2022
Frederick G Apt Individual Corporate OfficerTreasurer Jan 1, 2024
Providence Group NH, LLC Organization, Farmington, UT LLC, Holding company 5% Or Greater Direct Ownership Interest Jun 30, 2023 100%
Pacs Holdings, LLC Organization, Farmington, UT LLC, Holding company 5% Or Greater Indirect Ownership Interest Jun 30, 2023 100%
Joshua O Jergensen Individual Corporate OfficerPresident Jan 1, 2024
Pacs Group, Inc. Organization, Farmington, UT Corporation, Holding company, For-profit 5% Or Greater Indirect Ownership Interest Jun 30, 2023 100%
Mark D Hancock Individual 5% Or Greater Indirect Ownership Interest Apr 15, 2024 41.8%
Corporate OfficerCeo Jan 1, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 186

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 186

Practitioners & affiliated clinicians

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1150761600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724112000000",
    "number": "1013953199",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "262 N UNIVERSITY AVE",
            "city": "FARMINGTON",
            "state": "UT",
            "postal_code": "840252975"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1391 E MADISON AVE",
            "city": "EL CAJON",
            "state": "CA",
            "postal_code": "920218568",
            "telephone_number": "619-444-1107"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KOA HOLDINGS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-20",
        "last_updated": "2024-08-20",
        "certification_date": "2024-08-20",
        "status": "A",
        "authorized_official_last_name": "MITCHELL",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "385-988-3319"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "CA",
            "license": "090000071",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZT05064I",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "COTTONWOOD CANYON HEALTHCARE CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in El Cajon, CA

Sources for this page

Verify at the official NPI Registry.