Healthcare Provider Details

I. General information

NPI: 1114192697
Provider Name (Legal Business Name): MILLS-PENINSULA HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 TROUSDALE DR
BURLINGAME CA
94010-4520
US

IV. Provider business mailing address

PO BOX 742738
LOS ANGELES CA
90074-2738
US

V. Phone/Fax

Practice location:
  • Phone: 650-696-5270
  • Fax:
Mailing address:
  • Phone: 650-696-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number22000017
License Number StateCA

VIII. Authorized Official

Name: MR. BRIAN TRENT HUNTER
Title or Position: VP SHARED SERVICES
Credential:
Phone: 916-297-8555