Healthcare Provider Details

I. General information

NPI: 1306893904
Provider Name (Legal Business Name): 14766 WASHINGTON AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14766 WASHINGTON AVE
SAN LEANDRO CA
94578-4220
US

IV. Provider business mailing address

101 E STATE ST COMPLIANCE DEPARTMENT
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 510-352-2211
  • Fax: 510-352-2181
Mailing address:
  • Phone: 505-468-4742
  • Fax: 505-468-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number020000260
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number020000260
License Number StateCA

VIII. Authorized Official

Name: GEORGE V HAGER
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 505-821-3355