1760424261 NPI number — 1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC

Table of content: (NPI 1760424261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760424261 NPI number — 1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC
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:
KENTFIELD REHABILITATION & SPECIALTY 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:
1760424261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 17TH ST STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95354-1249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-287-6308
Provider Business Mailing Address Fax Number:
209-248-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 SIR FRANCIS DRAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENTFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-456-9680
Provider Business Practice Location Address Fax Number:
415-485-3696
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CFO/VP
Authorized Official Telephone Number:
209-287-6308

Provider Taxonomy Codes

  • Taxonomy code: 282E00000X , with the licence number:  110000358 , 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: 05-2043 . This is a "FREMONT HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "CORVEL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "HEALTH NET COMP 24" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "CCN INDUSTRIAL MEDICINE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HSP40554I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05-2043 . This is a "CCN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "FIRST HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "BEECH STREET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "MARIN IPA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "HEALTH NET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "INTERPLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HSC00554I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05-2043 . This is a "GENERAL REINSURANCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-2043 . This is a "FOUNDATION HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZR005541 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05-2043 . This is a "CAMP AMERICA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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