Basic Information
| Provider Information | |||||||||
| NPI: | 1972851392 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERIDIAN HEALTH SERVICES CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALL SAINTS SUBACUTE AND REHABILITATION CENTER - MAUBERT SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1652 MONO AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945782020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104813200 | ||||||||
| FaxNumber: | 5102787912 | ||||||||
| Practice Location | |||||||||
| Address1: | 15731 MAUBERT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945782014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104813200 | ||||||||
| FaxNumber: | 5102787912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PREIMESBERGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9258550881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERIDIAN HEALTH SERVICES HOLDINGS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 550002156 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 206014308 | 01 | CA | OSHPD | OTHER | 55-5879 | 01 | CA | MEDICARE ID - TYPE UNSPECIFIED | OTHER | 550002156 | 01 | CA | LICENSE | OTHER | 1972851392 | 01 | CA | NPI | OTHER |