Provider Demographics
NPI:1912996349
Name:ST MICHAEL CONVALESCENT HOSPITAL INC
Entity Type:Organization
Organization Name:ST MICHAEL CONVALESCENT HOSPITAL INC
Other - Org Name:VINTAGE ESTATES OF HAYWARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:RAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-782-3825
Mailing Address - Street 1:25919 GADING RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-2725
Mailing Address - Country:US
Mailing Address - Phone:510-782-3825
Mailing Address - Fax:510-782-8793
Practice Address - Street 1:25919 GADING RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-2725
Practice Address - Country:US
Practice Address - Phone:510-782-3825
Practice Address - Fax:510-782-8793
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SR ADMINISTRATIVE SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-18
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA760077117314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05359GMedicaid
CAZZR05359GMedicaid