Healthcare Provider Details

I. General information

NPI: 1255616280
Provider Name (Legal Business Name): KAISER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 168TH AVE
SAN LEANDRO CA
94578-2409
US

IV. Provider business mailing address

1440 168TH AVE
SAN LEANDRO CA
94578-2409
US

V. Phone/Fax

Practice location:
  • Phone: 510-481-6319
  • Fax:
Mailing address:
  • Phone: 510-481-6319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number943494
License Number StateCA

VIII. Authorized Official

Name: MS. TABASSUM MUNIR
Title or Position: CLINICAL DIETITIAN
Credential: RD
Phone: 510-481-6319