Healthcare Provider Details

I. General information

NPI: 1912192261
Provider Name (Legal Business Name): LIFEHOUSE SAN JOSE OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 N JACKSON AVE
SAN JOSE CA
95116-1907
US

IV. Provider business mailing address

329 NORTH REAL ROAD
BAKERSFIELD CA
93301-1820
US

V. Phone/Fax

Practice location:
  • Phone: 408-259-8700
  • Fax: 408-259-2343
Mailing address:
  • Phone: 661-327-7107
  • Fax: 661-327-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPENDING DHS APPROVAL
License Number StateCA

VIII. Authorized Official

Name: LOU ANDRIOTTI
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 310-337-1929