Provider Demographics
NPI:1700252137
Name:W.E. LODGE, INC
Entity Type:Organization
Organization Name:W.E. LODGE, INC
Other - Org Name:THE LODGE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ZIMMERMAN
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:510-748-4300
Mailing Address - Street 1:801 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-6762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 ISLAND DR
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-6762
Practice Address - Country:US
Practice Address - Phone:510-748-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA011440777310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility