Provider Demographics
NPI:1144221896
Name:BECHTHOLD CONVALESCENT HOSPITAL, INC
Entity Type:Organization
Organization Name:BECHTHOLD CONVALESCENT HOSPITAL, INC
Other - Org Name:CRESCENT COURT NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICIER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-897-5100
Mailing Address - Street 1:610 S FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3835
Mailing Address - Country:US
Mailing Address - Phone:209-367-7400
Mailing Address - Fax:209-368-4491
Practice Address - Street 1:610 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3835
Practice Address - Country:US
Practice Address - Phone:209-367-7400
Practice Address - Fax:209-368-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000014314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR55079IMedicaid
CA555079Medicare Oscar/Certification