Provider Demographics
NPI:1306835731
Name:GERIATRIC HEALTHCARE INC
Entity Type:Organization
Organization Name:GERIATRIC HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GRUIDL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:805-748-8897
Mailing Address - Street 1:PO BOX 2677
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-2677
Mailing Address - Country:US
Mailing Address - Phone:805-748-8897
Mailing Address - Fax:805-434-0308
Practice Address - Street 1:278 HACIENDA DR
Practice Address - Street 2:
Practice Address - City:CAYUCOS
Practice Address - State:CA
Practice Address - Zip Code:93430-1550
Practice Address - Country:US
Practice Address - Phone:805-748-8897
Practice Address - Fax:805-434-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW16850363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W16850Medicare ID - Type Unspecified