Provider Demographics
NPI:1215561444
Name:PORTOLA GARDENS LLC
Entity Type:Organization
Organization Name:PORTOLA GARDENS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CIMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-486-9639
Mailing Address - Street 1:350 UNIVERSITY STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134
Mailing Address - Country:US
Mailing Address - Phone:415-337-1587
Mailing Address - Fax:415-337-1573
Practice Address - Street 1:350 UNIVERSITY STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134
Practice Address - Country:US
Practice Address - Phone:415-337-1587
Practice Address - Fax:415-337-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility