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NPI Code Detail

MEDICARE: FRUITVALE LONG TERM CARE LLC

MEDICARE: FRUITVALE LONG TERM CARE LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1508295478
Entity Type Code : Organization
Provider Name (Legal Business Name) : FRUITVALE LONG TERM CARE LLC
Provider Business Mailing Address
First Line : 920 RIDGEBROOK RD
Second Line :
City : SPARKS
State : MD
Zip : 21152-9390
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3020 E 15TH ST
Second Line :
City : OAKLAND
State : CA
Zip : 94601-2305
Country : US
Telephone Number : 510-261-5613
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : KAM MCGAVOCK
Credential :
Telephone Number : 410-773-1000
Provider Enumeration Date : 11/01/2013
Last Update Date : 11/01/2013

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Directions to “FRUITVALE LONG TERM CARE LLC ” Practice Location

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