Provider Demographics
NPI:1760424261
Name:1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:1125 SIR FRANCIS DRAKE BOULEVARD OPERATING COMPANY, LLC
Other - Org Name:KENTFIELD REHABILITATION & SPECIALTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/VP
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-287-6308
Mailing Address - Street 1:700 17TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1249
Mailing Address - Country:US
Mailing Address - Phone:209-287-6308
Mailing Address - Fax:209-248-7825
Practice Address - Street 1:1125 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:415-456-9680
Practice Address - Fax:415-485-3696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000358282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-2043OtherFREMONT HEALTH
CA05-2043OtherCORVEL
CA05-2043OtherHEALTH NET COMP 24
CA05-2043OtherCCN INDUSTRIAL MEDICINE
CAHSP40554IMedicaid
CA05-2043OtherCCN
CA05-2043OtherFIRST HEALTH
CA05-2043OtherBEECH STREET
CA05-2043OtherMARIN IPA
CA05-2043OtherAETNA
CA05-2043OtherBLUE SHIELD
CA05-2043OtherBLUE CROSS
CA05-2043OtherHEALTH NET
CA05-2043OtherINTERPLAN
CAHSC00554IMedicaid
CA05-2043OtherGENERAL REINSURANCE
CA05-2043OtherFOUNDATION HEALTH
CAZZR005541Medicaid
CA05-2043OtherCAMP AMERICA
CA05-2043OtherFOUNDATION HEALTH
CABX627AMedicare PIN