Healthcare Provider Details

I. General information

NPI: 1336693654
Provider Name (Legal Business Name): ON CALL PROVIDER SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 86TH AVE
OAKLAND CA
94605-3907
US

IV. Provider business mailing address

2321 86TH AVE
OAKLAND CA
94605-3907
US

V. Phone/Fax

Practice location:
  • Phone: 510-325-1734
  • Fax: 510-562-6493
Mailing address:
  • Phone: 510-325-1734
  • Fax: 510-562-6493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number14579
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1003009275
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerNPI

VIII. Authorized Official

Name: MS. SHARONNE ELAINE ROGERS
Title or Position: CEO
Credential: FNP
Phone: 510-325-1734