Healthcare Provider Details

I. General information

NPI: 1093704249
Provider Name (Legal Business Name): LINCOLN GLEN SKILLED NURSING FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2671 PLUMMER AVE
SAN JOSE CA
95125-4867
US

IV. Provider business mailing address

2671 PLUMMER AVE
SAN JOSE CA
95125-4867
US

V. Phone/Fax

Practice location:
  • Phone: 408-265-3222
  • Fax: 408-448-1533
Mailing address:
  • Phone: 408-265-3222
  • Fax: 408-448-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number31400000X
License Number StateCA

VIII. Authorized Official

Name: JAMES BRADLEY MORTENSEN
Title or Position: EXECUTIVE DIRECTOR
Credential: LNHA
Phone: 408-757-8580