1194716712 NPI number — CONVALESCENT CENTER MISSION ST. INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194716712 NPI number — CONVALESCENT CENTER MISSION ST. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONVALESCENT CENTER MISSION ST. 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:
SAN FRANCISCO NURSING CENTER
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:
1194716712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 EXECUTIVE PKWY
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
SAN RAMON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94583-4210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-855-0881
Provider Business Mailing Address Fax Number:
925-855-9297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5767 MISSION ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-584-3294
Provider Business Practice Location Address Fax Number:
415-584-7714
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PREIMESBERGER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
925-855-0881

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZR06449I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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