Healthcare Provider Details

I. General information

NPI: 1174518088
Provider Name (Legal Business Name): OAK KNOLL CONVALESCENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 HAYES LN
PETALUMA CA
94952-4010
US

IV. Provider business mailing address

450 HAYES LN
PETALUMA CA
94952-4010
US

V. Phone/Fax

Practice location:
  • Phone: 707-778-8686
  • Fax: 707-778-6111
Mailing address:
  • Phone: 707-778-8686
  • Fax: 707-778-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number010000053
License Number StateCA

VIII. Authorized Official

Name: MR. ANTHONY R. MEYERS
Title or Position: CEO
Credential:
Phone: 707-778-8686