Healthcare Provider Details

I. General information

NPI: 1063157626
Provider Name (Legal Business Name): 991 CLYDE AVENUE OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 CLYDE AVE
SANTA CLARA CA
95054-1905
US

IV. Provider business mailing address

991 CLYDE AVE
SANTA CLARA CA
95054-1905
US

V. Phone/Fax

Practice location:
  • Phone: 724-463-3570
  • Fax:
Mailing address:
  • Phone: 408-988-7667
  • Fax: 408-643-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: AVROHOM TRESS
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 310-390-9506