Provider Demographics
NPI:1093704249
Name:LINCOLN GLEN SKILLED NURSING FACILITY
Entity Type:Organization
Organization Name:LINCOLN GLEN SKILLED NURSING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MADRIAGA
Authorized Official - Suffix:
Authorized Official - Credentials:ACCOUNTING DIRECTOR
Authorized Official - Phone:408-265-3222
Mailing Address - Street 1:2671 PLUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-4867
Mailing Address - Country:US
Mailing Address - Phone:408-265-3222
Mailing Address - Fax:408-448-1533
Practice Address - Street 1:2671 PLUMMER AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-4867
Practice Address - Country:US
Practice Address - Phone:408-265-3222
Practice Address - Fax:408-448-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31400000X314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555363Medicare Oscar/Certification