Provider Demographics
NPI:1811036957
Name:SP FACILITY INC
Entity Type:Organization
Organization Name:SP FACILITY INC
Other - Org Name:BROOKVUE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTERDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-899-7999
Mailing Address - Street 1:13328 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3902
Mailing Address - Country:US
Mailing Address - Phone:510-235-3720
Mailing Address - Fax:
Practice Address - Street 1:13328 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3902
Practice Address - Country:US
Practice Address - Phone:510-235-3720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06359IMedicaid
CA05-6359Medicare ID - Type UnspecifiedMEDICARE PROVIDER