Provider Demographics
NPI:1467548461
Name:TRINITY OAKLAND, INC
Entity Type:Organization
Organization Name:TRINITY OAKLAND, INC
Other - Org Name:ROSE CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-820-9750
Mailing Address - Street 1:3541 PUENTE AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5534
Mailing Address - Country:US
Mailing Address - Phone:626-962-1043
Mailing Address - Fax:626-337-2142
Practice Address - Street 1:3541 PUENTE AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5534
Practice Address - Country:US
Practice Address - Phone:626-962-1043
Practice Address - Fax:626-337-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18512HMedicaid
CA555107Medicare ID - Type Unspecified