Healthcare Provider Details

I. General information

NPI: 1154478360
Provider Name (Legal Business Name): CLINTON VILLAGE CONVALESCENT HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 10TH AVE
OAKLAND CA
94606-3023
US

IV. Provider business mailing address

1833 10TH AVE
OAKLAND CA
94606-3023
US

V. Phone/Fax

Practice location:
  • Phone: 510-536-6512
  • Fax: 510-536-1450
Mailing address:
  • Phone: 510-536-6512
  • Fax: 510-536-1450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: FERMER LUKBAN
Title or Position: MANAGER
Credential:
Phone: 510-536-6512