1699720862 NPI number — BAYWOOD COURT SKILLED NURSING FACILITY

Table of content: LUIS ALBERTO BOUZAS COSIO (NPI 1801655055)

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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