Healthcare Provider Details

I. General information

NPI: 1194716712
Provider Name (Legal Business Name): CONVALESCENT CENTER MISSION ST. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5767 MISSION ST.
SAN FRANCISCO CA
94112
US

IV. Provider business mailing address

5000 EXECUTIVE PKWY SUITE 150
SAN RAMON CA
94583-4210
US

V. Phone/Fax

Practice location:
  • Phone: 415-584-3294
  • Fax: 415-584-7714
Mailing address:
  • Phone: 925-855-0881
  • Fax: 925-855-9297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES PREIMESBERGER
Title or Position: PRESIDENT
Credential:
Phone: 925-855-0881