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Organization
ST JOHN KRONSTADT HOME FOR AGED RUSSIAN AMERICANS
Active
Organization
ST JOHN KRONSTADT HOME FOR AGED RUSSIAN AMERICANS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEREMY E GRIMES (MANAGER)
(925) 855-0881
Entity
Organization
Contact information
Practice address
4432 JAMES AVE, CASTRO VALLEY, CA 94546-3533
(510) 889-7000
(510) 889-7622
Mailing address
5000 EXECUTIVE PKWY, SUITE 150, SAN RAMON, CA 94583-4210
(925) 855-0881
(925) 855-9297
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
020000104
CA
332B00000X
Durable Medical Equipment & Medical Supplies
020000104
CA
332BN1400X
Nursing Facility Supplies (DME)
020000104
CA
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
020000104
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ZZR 55016G
—
CA
Enumeration date
08/16/2005
Last updated
06/23/2011
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