Basic Information
| Provider Information | |||||||||
| NPI: | 1205213105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN BRUNOIDENCE OPCO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN BRUNO SKILLED NURSING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 N UNION AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014479829 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 890 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | SAN BRUNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940663137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505837768 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8014479829 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.