=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689063489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST ANTHONY SERENETHOS SNF,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2015
-----------------------------------------------------
Last Update Date | 02/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 553 SMALLEY AVE
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94541-4919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-733-3877
-----------------------------------------------------
Fax | 510-446-8631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 553 SMALLEY AVE
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94541-4919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-733-3877
-----------------------------------------------------
Fax | 510-446-8631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | QING XIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 151-073-3387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------