Healthcare Provider Details

I. General information

NPI: 1902329782
Provider Name (Legal Business Name): AGSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 S ELISEO DR
GREENBRAE CA
94904-2006
US

IV. Provider business mailing address

28202 CABOT RD STE 412
LAGUNA NIGUEL CA
92677-1271
US

V. Phone/Fax

Practice location:
  • Phone: 415-461-9700
  • Fax:
Mailing address:
  • Phone: 949-347-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10000354
License Number StateCA

VIII. Authorized Official

Name: JEFFREY BRADSHAW
Title or Position: MANAGER
Credential:
Phone: 949-347-7100