Provider Demographics
NPI:1306280839
Name:SOUTH COUNTY RETIREMENT HOME
Entity type:Organization
Organization Name:SOUTH COUNTY RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:CALMA
Authorized Official - Last Name:APOSTOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-683-0229
Mailing Address - Street 1:460 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARTIN
Mailing Address - State:CA
Mailing Address - Zip Code:95046-9778
Mailing Address - Country:US
Mailing Address - Phone:408-683-0229
Mailing Address - Fax:408-683-0278
Practice Address - Street 1:460 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:SAN MARTIN
Practice Address - State:CA
Practice Address - Zip Code:95046-9778
Practice Address - Country:US
Practice Address - Phone:408-683-0229
Practice Address - Fax:408-683-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA435294143310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility