=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114053220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN MATEO CONVALESCENT HOSPITAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 453 N SAN MATEO DR
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-342-6255
-----------------------------------------------------
Fax | 650-342-4812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 453 N SAN MATEO DR
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-342-6255
-----------------------------------------------------
Fax | 650-342-4812
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. PATRICIA A BARNES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-342-6255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------