NPIMap

Organization Active NPI

Watermanidence Opco, LLC

  • Skilled Nursing Facility
  • San Bernardino, CA
National Provider Identifier
1750789046
Registry record updated Aug 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
WATERMANIDENCE OPCO, LLC
Doing business as
Waterman Canyon Post Acute
Practice address
1850 N Waterman Ave
San Bernardino, CA 92404-4831
Phone
(909) 882-1215
Fax
(909) 881-2071
NPI assigned
Dec 18, 2014
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 Primary

Addresses

Primary practice location

1850 N Waterman Ave
San Bernardino, CA 92404-4831

Mailing address

262 N University Ave
Farmington, UT 84025-2975

Other names 1

  • Waterman Canyon Post Acute Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150622001288 CA Part A Provider - Skilled Nursing Facility 6103137849 Practice locations: San Bernardino, CA

Skilled nursing facility certification: CCN 055565

Legal name
WATERMANIDENCE OPCO LLC
Doing business as
WATERMAN CANYON POST ACUTE
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 1, 1971
Last certification
Mar 21, 2025
Beds
166
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Incorporated
Dec 17, 2014 in CA
Enrollment address
1850 N Waterman Ave
San Bernardino, CA 92404-4831
Nursing home name
WATERMAN CANYON POST ACUTE
Affiliated entity
PACS GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Waterman Canyon Post AcuteCCN 055565 · All quality measures
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
2 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jan 1, 1971
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
166153.9 residents per day on average
Chain
Pacs Group274 facilities in the chain

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
05D0713912Waterman Canyon Post Acute1850 N Waterman Ave, San Bernardino, CA 92404Certificate of waiverAug 31, 2026

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
Jason H Murray Individual 5% Or Greater Indirect Ownership Interest Apr 15, 2024 41.8%
John T Mitchell Individual Corporate OfficerSecretary Jan 1, 2024
Nicoletta Jenkins Individual W-2 Managing EmployeeAdministrator May 1, 2022
Operational/Managerial ControlAdministrator May 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
Sepehr Golboo Individual Contracted Managing EmployeeMD; Sep 1, 2022
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": "1418860800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724112000000",
    "number": "1750789046",
    "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": "1850 N WATERMAN AVE",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924044831",
            "telephone_number": "909-882-1215",
            "fax_number": "909-881-2071"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATERMANIDENCE OPCO, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-18",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Waterman Canyon Post Acute",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Bernardino, CA

Sources for this page

Verify at the official NPI Registry.