Healthcare Provider Details

I. General information

NPI: 1508295478
Provider Name (Legal Business Name): FRUITVALE LONG TERM CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 E 15TH ST
OAKLAND CA
94601-2305
US

IV. Provider business mailing address

920 RIDGEBROOK RD
SPARKS MD
21152-9390
US

V. Phone/Fax

Practice location:
  • Phone: 510-261-5613
  • Fax:
Mailing address:
  • Phone:
  • 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: KAM MCGAVOCK
Title or Position: PRESIDENT
Credential:
Phone: 410-773-1000