Provider Demographics
NPI:1346386620
Name:DEGROOT NURSING HOME
Entity Type:Organization
Organization Name:DEGROOT NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIAANTJE
Authorized Official - Middle Name:SJANY
Authorized Official - Last Name:DE GROOT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:805-543-7663
Mailing Address - Street 1:1015 BUCHON ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4021
Mailing Address - Country:US
Mailing Address - Phone:805-543-7663
Mailing Address - Fax:805-544-7967
Practice Address - Street 1:1015 BUCHON ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4021
Practice Address - Country:US
Practice Address - Phone:805-543-7663
Practice Address - Fax:805-544-7967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80007FOtherMEDI-CAL ID NUMBER