Provider Demographics
NPI:1598718082
Name:RANCHO SAN ANTONIO RETIREMENT SERVICES, INC.
Entity Type:Organization
Organization Name:RANCHO SAN ANTONIO RETIREMENT SERVICES, INC.
Other - Org Name:HEALTH CARE CENTER AT THE FORUM AT RANCHO SAN ANTONIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GENDZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-988-9300
Mailing Address - Street 1:23600 VIA ESPLENDOR
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-6571
Mailing Address - Country:US
Mailing Address - Phone:650-944-0200
Mailing Address - Fax:650-903-5920
Practice Address - Street 1:23600 VIA ESPLENDOR
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-6571
Practice Address - Country:US
Practice Address - Phone:650-944-0200
Practice Address - Fax:650-903-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000444314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherBLUE CROSS BLUE SHEILD
CA=========OtherAETNA
CA=========OtherUNITED HEALTHCARE
CA=========OtherAARP
CA=========OtherTRICARE
CA=========OtherTRICARE