1972601987 NPI number — VIP CARE MANAGEMENT INC

Table of content: (NPI 1972601987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972601987 NPI number — VIP CARE MANAGEMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIP CARE MANAGEMENT INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASHBY CARE CENTER ASHBY GERIATRIC HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972601987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 DIAS COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL SOBRANTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-223-1252
Provider Business Mailing Address Fax Number:
510-223-1252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2270 ASHBY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-841-9494
Provider Business Practice Location Address Fax Number:
510-841-1120
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEDIACHVILI
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
415-867-4033

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LTM90004 I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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