=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306893904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 14766 WASHINGTON AVENUE OPERATIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2006
-----------------------------------------------------
Last Update Date | 03/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14766 WASHINGTON AVE
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94578-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-352-2211
-----------------------------------------------------
Fax | 510-352-2181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 E STATE ST COMPLIANCE DEPARTMENT
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-3109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-468-4742
-----------------------------------------------------
Fax | 505-468-8742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DIRECTOR
-----------------------------------------------------
Name | GEORGE V HAGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-821-3355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | 020000260
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 020000260
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------