Healthcare Provider Details

I. General information

NPI: 1972501823
Provider Name (Legal Business Name): VIENNA CONVALESCENT HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S HAM LN
LODI CA
95242-3543
US

IV. Provider business mailing address

800 S HAM LN
LODI CA
95242-3543
US

V. Phone/Fax

Practice location:
  • Phone: 209-368-7141
  • Fax: 209-368-2163
Mailing address:
  • Phone: 209-368-7141
  • Fax: 209-368-2163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100000111
License Number StateCA

VIII. Authorized Official

Name: MR. COREY WRIGHT
Title or Position: ADMINISTRATOR
Credential:
Phone: 209-368-7141