Provider Demographics
NPI:1386732006
Name:PENINSULA CONVALESCENT ASSOCIATES LLC
Entity type:Organization
Organization Name:PENINSULA CONVALESCENT ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VIEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-591-9601
Mailing Address - Street 1:2140 CARLMONT DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3417
Mailing Address - Country:US
Mailing Address - Phone:650-591-9601
Mailing Address - Fax:650-591-2446
Practice Address - Street 1:2140 CARLMONT DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3417
Practice Address - Country:US
Practice Address - Phone:650-591-9601
Practice Address - Fax:650-591-2446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000004314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55657GMedicaid
CA555657Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.