Provider Demographics
NPI:1033221999
Name:YOSEMITE CONVALESCENT HOSPITAL, INC.
Entity Type:Organization
Organization Name:YOSEMITE CONVALESCENT HOSPITAL, INC.
Other - Org Name:COLONY PARK NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ARDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-673-5149
Mailing Address - Street 1:632 E YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-3343
Mailing Address - Country:US
Mailing Address - Phone:559-673-5149
Mailing Address - Fax:559-673-7249
Practice Address - Street 1:159 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5334
Practice Address - Country:US
Practice Address - Phone:209-526-2811
Practice Address - Fax:209-526-6193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05849FMedicaid
CA05-5849Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER