Basic Information
| Provider Information | |||||||||
| NPI: | 1740309103 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 3555 CEASAR CHAVEZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 CESAR CHAVEZ | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941104403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156478600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3555 CESAR CHAVEZ | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941104403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156478600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOLDSWORTH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF ADMIN CFO | ||||||||
| AuthorizedOfficialTelephone: | 4156003959 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 220000070 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC70042F | 05 | CA | MEDICAID |