Provider Demographics
NPI:1154496867
Name:KAISER FOUNDATION HOSPITALS
Entity Type:Organization
Organization Name:KAISER FOUNDATION HOSPITALS
Other - Org Name:KAISER FOUNDATION HOSPITAL-MANTECA DPSNF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP/AREA MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-735-4146
Mailing Address - Street 1:1777 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5130
Mailing Address - Country:US
Mailing Address - Phone:209-825-3625
Mailing Address - Fax:209-825-3627
Practice Address - Street 1:1777 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5130
Practice Address - Country:US
Practice Address - Phone:209-825-3625
Practice Address - Fax:209-825-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000393314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55601HMedicaid
CALTC70075HMedicaid
CAGR0093734Medicaid
CA55-5601Medicare Oscar/Certification