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NPI Code Detail

MEDICARE: SAN BRUNOIDENCE OPCO, LLC

MEDICARE: SAN BRUNOIDENCE OPCO, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing FacilityCA

General Provider Information

NPI Number : 1205213105
Entity Type Code : Organization
Provider Name (Legal Business Name) : SAN BRUNOIDENCE OPCO, LLC
Provider Business Mailing Address
First Line : 262 N UNIVERSITY AVE
Second Line :
City : FARMINGTON
State : UT
Zip : 84025-2975
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 890 EL CAMINO REAL
Second Line :
City : SAN BRUNO
State : CA
Zip : 94066-3137
Country : US
Telephone Number : 650-583-7768
Fax Number :
Authorized Official
Title or Position : SECRETARY
Name : JOHN MITCHELL
Credential :
Telephone Number : 385-988-3319
Provider Enumeration Date : 04/29/2015
Last Update Date : 08/20/2024

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Directions to “SAN BRUNOIDENCE OPCO, LLC ” Practice Location

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