1699720862 NPI number — BAYWOOD COURT SKILLED NURSING FACILITY

Table of content: (NPI 1699720862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699720862 NPI number — BAYWOOD COURT SKILLED NURSING FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYWOOD COURT SKILLED NURSING FACILITY
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:
Provider Other Organization Name Type Code:
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:
1699720862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3012 SUMMIT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-3480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-869-6591
Provider Business Mailing Address Fax Number:
510-869-6592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20103 LAKE CHABOT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTRO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94546-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-727-8290
Provider Business Practice Location Address Fax Number:
510-582-1730
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DERBEDROSIAN
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL DIRECTOR - PFS
Authorized Official Telephone Number:
510-869-6163

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  140000030 , 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: LTC55454G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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