Basic Information
| Provider Information | |||||||||
| NPI: | 1306893904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 14766 WASHINGTON AVENUE OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHINGTON CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Practice Location | |||||||||
| Address1: | 14766 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945784220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103522211 | ||||||||
| FaxNumber: | 5103522181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | HAGER | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 020000260 | CA | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 314000000X | 020000260 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 850370802 | 01 | CA | HEARTLAND HOSPICE | OTHER | 850370802 | 01 | CA | AAARP | OTHER | 850370802 | 01 | CA | UNITED AMERICAN INS CO. | OTHER | ZZR06121I | 05 | CA | MEDICAID | 850370802 | 01 | CA | VNA HOSPICE | OTHER | 850370802 | 01 | CA | HEALTH NET FLEX BENEFITS | OTHER | 850370802 | 01 | CA | KASIER | OTHER | 850370802 | 01 | CA | UTA/HUMANA | OTHER |