Healthcare Provider Details

I. General information

NPI: 1144856535
Provider Name (Legal Business Name): FRUITVALE OPERATING COMPANY, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 E 15TH ST
OAKLAND CA
94601-2305
US

IV. Provider business mailing address

3060 MERCER UNIVERSITY DR STE 200
ATLANTA GA
30341-4135
US

V. Phone/Fax

Practice location:
  • Phone: 510-261-5613
  • Fax:
Mailing address:
  • Phone: 678-443-6772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: LINDA W TAETZ
Title or Position: PRESIDENT
Credential:
Phone: 805-804-8111