Provider Demographics
NPI:1447297171
Name:LAUREL GROVE HOSPITAL-REHAB UNIT
Entity type:Organization
Organization Name:LAUREL GROVE HOSPITAL-REHAB UNIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP SHARED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-297-8555
Mailing Address - Street 1:PO BOX 748373
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-8373
Mailing Address - Country:US
Mailing Address - Phone:855-398-1633
Mailing Address - Fax:510-869-6592
Practice Address - Street 1:19933 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4003
Practice Address - Country:US
Practice Address - Phone:510-582-1730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDEN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140000030273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP30095JMedicaid
CA05T095Medicare Oscar/Certification