Provider Demographics
NPI:1275670895
Name:SSC OAKLAND FRUITVALE OPERATING COMPANY LP
Entity Type:Organization
Organization Name:SSC OAKLAND FRUITVALE OPERATING COMPANY LP
Other - Org Name:FRUITVALE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR AR
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-5728
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:3020 E 15TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2305
Practice Address - Country:US
Practice Address - Phone:510-261-5613
Practice Address - Fax:510-261-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000067314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC90060HMedicaid
CA555358Medicare Oscar/Certification