Provider Demographics
NPI:1124178645
Name:RAFAEL CONVALESCENT HOSPITAL
Entity Type:Organization
Organization Name:RAFAEL CONVALESCENT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-479-3450
Mailing Address - Street 1:234 N SAN PEDRO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2858
Mailing Address - Country:US
Mailing Address - Phone:415-479-3450
Mailing Address - Fax:415-472-3723
Practice Address - Street 1:234 N SAN PEDRO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2858
Practice Address - Country:US
Practice Address - Phone:415-479-3450
Practice Address - Fax:415-472-3723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05310F4Medicaid
CAZZR05310F4Medicaid