Provider Demographics
NPI:1154478360
Name:CLINTON VILLAGE CONVALESCENT HOSPITAL
Entity Type:Organization
Organization Name:CLINTON VILLAGE CONVALESCENT HOSPITAL
Other - Org Name:PROTEAN HEALTHCARE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FERMER
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKBAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-536-6512
Mailing Address - Street 1:1833 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3023
Mailing Address - Country:US
Mailing Address - Phone:510-536-6512
Mailing Address - Fax:510-536-1450
Practice Address - Street 1:1833 10TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-3023
Practice Address - Country:US
Practice Address - Phone:510-536-6512
Practice Address - Fax:510-536-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06341IMedicaid
CA056341Medicare ID - Type Unspecified