Provider Demographics
NPI:1306893904
Name:14766 WASHINGTON AVENUE OPERATIONS LLC
Entity type:Organization
Organization Name:14766 WASHINGTON AVENUE OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-821-3355
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:505-468-4742
Mailing Address - Fax:505-468-8742
Practice Address - Street 1:14766 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-4220
Practice Address - Country:US
Practice Address - Phone:510-352-2211
Practice Address - Fax:510-352-2181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000260311500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA850370802OtherHEARTLAND HOSPICE
CA850370802OtherAAARP
CA850370802OtherUNITED AMERICAN INS CO.
CAZZR06121IMedicaid
CA850370802OtherVNA HOSPICE
CA850370802OtherHEALTH NET FLEX BENEFITS
CA850370802OtherKASIER
CA850370802OtherUTA/HUMANA
CAZZR06121IMedicaid
0617110006Medicare NSC