Provider Demographics
NPI:1558545384
Name:CLINTON VILLAGE CONVALESCENT HOSPITAL
Entity Type:Organization
Organization Name:CLINTON VILLAGE CONVALESCENT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-537-7088
Mailing Address - Street 1:1833 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3023
Mailing Address - Country:US
Mailing Address - Phone:510-536-6510
Mailing Address - Fax:510-536-4319
Practice Address - Street 1:1833 10TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-3023
Practice Address - Country:US
Practice Address - Phone:510-536-6510
Practice Address - Fax:510-536-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALTC90086F282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC90086FMedicaid