Provider Demographics
NPI:1144524455
Name:MILLBRAE MANOR, INC
Entity type:Organization
Organization Name:MILLBRAE MANOR, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMPARO
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAGUDO
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:408-315-9294
Mailing Address - Street 1:5330 AREZZO DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-2201
Mailing Address - Country:US
Mailing Address - Phone:408-315-9294
Mailing Address - Fax:408-226-3800
Practice Address - Street 1:1001 HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-2046
Practice Address - Country:US
Practice Address - Phone:650-689-5778
Practice Address - Fax:650-689-5783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility