Healthcare Provider Details

I. General information

NPI: 1386732006
Provider Name (Legal Business Name): PENINSULA CONVALESCENT ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 CARLMONT DR
BELMONT CA
94002-3417
US

IV. Provider business mailing address

2140 CARLMONT DR
BELMONT CA
94002-3417
US

V. Phone/Fax

Practice location:
  • Phone: 650-591-9601
  • Fax: 650-591-2446
Mailing address:
  • Phone: 650-591-9601
  • Fax: 650-591-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number220000004
License Number StateCA

VIII. Authorized Official

Name: LINDA ANN VIEIRA
Title or Position: CONTROLLER
Credential:
Phone: 650-591-9601