Provider Demographics
NPI:1629097761
Name:PALM HAVEN NURSING & REHAB LLC
Entity Type:Organization
Organization Name:PALM HAVEN NURSING & REHAB LLC
Other - Org Name:ST JUDE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PALLIVATHUCAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-823-1788
Mailing Address - Street 1:469 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336
Mailing Address - Country:US
Mailing Address - Phone:209-823-1788
Mailing Address - Fax:209-823-9809
Practice Address - Street 1:469 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:209-823-1788
Practice Address - Fax:209-823-9809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000071314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05917HMedicaid
CA055917Medicare Oscar/Certification