Provider Demographics
NPI:1194716712
Name:CONVALESCENT CENTER MISSION ST. INC.
Entity type:Organization
Organization Name:CONVALESCENT CENTER MISSION ST. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PREIMESBERGER
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 1:5767 MISSION ST.
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112
Practice Address - Country:US
Practice Address - Phone:415-584-3294
Practice Address - Fax:415-584-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06449IMedicaid
CAZZR06449IMedicaid
CA056449Medicare ID - Type Unspecified