Provider Demographics
NPI:1114115417
Name:FERN LODGE, INC.
Entity type:Organization
Organization Name:FERN LODGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:STRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-886-2448
Mailing Address - Street 1:18457 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-1637
Mailing Address - Country:US
Mailing Address - Phone:510-886-2448
Mailing Address - Fax:510-886-5992
Practice Address - Street 1:18457 MADISON AVE
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-1637
Practice Address - Country:US
Practice Address - Phone:510-886-2448
Practice Address - Fax:510-886-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution
Provider Identifiers
StateIdentifier IDID TypeIssuer
051994Medicare Oscar/Certification