Provider Demographics
NPI:1871661967
Name:LONE TREE CONVALESCENT HOSPITAL, INC.
Entity Type:Organization
Organization Name:LONE TREE CONVALESCENT HOSPITAL, INC.
Other - Org Name:LONE TREE CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-383-4810
Mailing Address - Street 1:4001 LONE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6232
Mailing Address - Country:US
Mailing Address - Phone:925-754-0470
Mailing Address - Fax:925-754-9142
Practice Address - Street 1:4001 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6232
Practice Address - Country:US
Practice Address - Phone:925-754-0470
Practice Address - Fax:925-754-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140000199314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06021HMedicaid
CA056021Medicare Oscar/Certification