Provider Demographics
NPI:1467326058
Name:MAMA ANGELINA COCONOCHO LLC
Entity type:Organization
Organization Name:MAMA ANGELINA COCONOCHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA ROSARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:951-335-1239
Mailing Address - Street 1:862 PIKE DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-7823
Mailing Address - Country:US
Mailing Address - Phone:951-335-1239
Mailing Address - Fax:951-305-6884
Practice Address - Street 1:862 PIKE DR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-7823
Practice Address - Country:US
Practice Address - Phone:951-335-1239
Practice Address - Fax:951-305-6884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility