Provider Demographics
NPI:1720035090
Name:MANOR CARE OF WALNUT CREEK CA LLC
Entity Type:Organization
Organization Name:MANOR CARE OF WALNUT CREEK CA LLC
Other - Org Name:PROMEDICA SKILLED NURSING AND REHABILITATION (ROSSMOOR)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5734
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-5500
Mailing Address - Fax:877-385-9446
Practice Address - Street 1:1226 ROSSMOOR PKWY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2538
Practice Address - Country:US
Practice Address - Phone:925-975-5000
Practice Address - Fax:925-937-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140000368314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720035090Medicaid
CA555446Medicare Oscar/Certification