Provider Demographics
NPI:1346714425
Name:EMERALD BLOSSOM MANOR, LLC.
Entity Type:Organization
Organization Name:EMERALD BLOSSOM MANOR, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:KILTHAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:669-234-3344
Mailing Address - Street 1:5301 GERINE BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-2118
Mailing Address - Country:US
Mailing Address - Phone:669-234-3344
Mailing Address - Fax:669-500-7377
Practice Address - Street 1:5301 GERINE BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-2118
Practice Address - Country:US
Practice Address - Phone:669-234-3344
Practice Address - Fax:669-500-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities