Provider Demographics
NPI:1861484982
Name:ST JOHN KRONSTADT HOME FOR AGED RUSSIAN AMERICANS
Entity Type:Organization
Organization Name:ST JOHN KRONSTADT HOME FOR AGED RUSSIAN AMERICANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-855-0881
Mailing Address - Street 1:5000 EXECUTIVE PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4210
Mailing Address - Country:US
Mailing Address - Phone:925-855-0881
Mailing Address - Fax:925-855-9297
Practice Address - Street 1:4432 JAMES AVE
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-3533
Practice Address - Country:US
Practice Address - Phone:510-889-7000
Practice Address - Fax:510-889-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000104314000000X, 332B00000X, 332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR 55016GMedicaid
CAZZR 55016GMedicaid
CA55-5016Medicare ID - Type Unspecified