Provider Demographics
NPI:1760665178
Name:PALM DRIVE NURSING & REHAB CENTER
Entity Type:Organization
Organization Name:PALM DRIVE NURSING & REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-829-4300
Mailing Address - Street 1:501 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4215
Mailing Address - Country:US
Mailing Address - Phone:707-823-8511
Mailing Address - Fax:707-829-4136
Practice Address - Street 1:477 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4206
Practice Address - Country:US
Practice Address - Phone:707-823-8511
Practice Address - Fax:707-829-4136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALM DRIVE HEALTH CARE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05520KMedicaid
CAZZR05520KMedicaid