Provider Demographics
NPI:1629042833
Name:CALIFORNIA-NEVADA METHODIST HOMES
Entity Type:Organization
Organization Name:CALIFORNIA-NEVADA METHODIST HOMES
Other - Org Name:LAKE PARK RETIREMENT RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-893-8989
Mailing Address - Street 1:201 19TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-4117
Mailing Address - Country:US
Mailing Address - Phone:510-893-8989
Mailing Address - Fax:510-893-3041
Practice Address - Street 1:1850 ALICE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-4175
Practice Address - Country:US
Practice Address - Phone:510-835-5511
Practice Address - Fax:510-273-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000057314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
555113Medicare ID - Type UnspecifiedMEDICARE PROVIDE NUMBER