Healthcare Provider Details

I. General information

NPI: 1144524455
Provider Name (Legal Business Name): MILLBRAE MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2010
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HEMLOCK AVE
MILLBRAE CA
94030-2046
US

IV. Provider business mailing address

5330 AREZZO DR
SAN JOSE CA
95138-2201
US

V. Phone/Fax

Practice location:
  • Phone: 650-689-5778
  • Fax: 650-689-5783
Mailing address:
  • Phone: 408-315-9294
  • Fax: 408-226-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMPARO B RAGUDO
Title or Position: CFO
Credential: NHA
Phone: 408-315-9294