Provider Demographics
NPI:1659461408
Name:ST. THERESE CONVALESCENT HOSPITAL ,INC.
Entity Type:Organization
Organization Name:ST. THERESE CONVALESCENT HOSPITAL ,INC.
Other - Org Name:DEVONSHIRE OAKS NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANILO
Authorized Official - Middle Name:CARDENAS
Authorized Official - Last Name:CABANAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:650-366-0294
Mailing Address - Street 1:3635 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3148
Mailing Address - Country:US
Mailing Address - Phone:650-366-0294
Mailing Address - Fax:650-366-0295
Practice Address - Street 1:3635 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-3148
Practice Address - Country:US
Practice Address - Phone:650-366-0294
Practice Address - Fax:650-366-0295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55813FMedicaid
CA555813Medicare ID - Type UnspecifiedLTC