Provider Demographics
NPI:1073575338
Name:SHORELINE SOUTH INTERMEDIATE CARE, INC.
Entity Type:Organization
Organization Name:SHORELINE SOUTH INTERMEDIATE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-523-8857
Mailing Address - Street 1:430 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6130
Mailing Address - Country:US
Mailing Address - Phone:510-523-8857
Mailing Address - Fax:510-523-8940
Practice Address - Street 1:430 WILLOW ST
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-6130
Practice Address - Country:US
Practice Address - Phone:510-523-8857
Practice Address - Fax:510-523-8940
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTLINE MEDICAL MANAGERMENT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000268314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR18475IMedicaid
CA55-5486Medicare ID - Type Unspecified
CALTC70132FMedicare ID - Type Unspecified