Provider Demographics
NPI:1346232469
Name:SAN BRUNO SKILLED NURSING HOSPITAL, INC.
Entity Type:Organization
Organization Name:SAN BRUNO SKILLED NURSING HOSPITAL, INC.
Other - Org Name:SAN BRUNO SKILLED NURSING HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PREIMESBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-503-4114
Mailing Address - Street 1:5000 EXECUTIVE PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4210
Mailing Address - Country:US
Mailing Address - Phone:925-855-0881
Mailing Address - Fax:925-855-9297
Practice Address - Street 1:890 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3137
Practice Address - Country:US
Practice Address - Phone:650-583-7768
Practice Address - Fax:650-583-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000042314000000X, 332B00000X, 332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR18193GMedicaid
CA555276Medicare Oscar/Certification
CAZZR18193GMedicaid