1730228867 NPI number — GOLDEN AGE CONVALESCENT HOSPITAL, INC

Table of content: (NPI 1730228867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730228867 NPI number — GOLDEN AGE CONVALESCENT HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN AGE CONVALESCENT HOSPITAL, 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:
Provider Other Organization Name Type Code:
6
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:
1730228867
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:
523 BURLINGAME AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPITOLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95010-3307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-475-0722
Provider Business Mailing Address Fax Number:
831-475-1048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 BURLINGAME AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPITOLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95010-3307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-475-0722
Provider Business Practice Location Address Fax Number:
831-475-1048
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAPANG
Authorized Official First Name:
ESTERLITA
Authorized Official Middle Name:
CORTES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
408-761-7000

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: ZZR18415K , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com