Provider Demographics
NPI:1174518088
Name:OAK KNOLL CONVALESCENT CENTER, INC.
Entity type:Organization
Organization Name:OAK KNOLL CONVALESCENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-778-8686
Mailing Address - Street 1:450 HAYES LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4010
Mailing Address - Country:US
Mailing Address - Phone:707-778-8686
Mailing Address - Fax:707-778-6111
Practice Address - Street 1:450 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4010
Practice Address - Country:US
Practice Address - Phone:707-778-8686
Practice Address - Fax:707-778-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000053314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55172FMedicaid
CA55-5127Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER