1356798383 NPI number — CHILDRENS CRISIS INTERVENTION PROGRAM

Table of content: DR. NARESH YEDTHARE SHETTY BDS, MDS, PHD (NPI 1366330631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356798383 NPI number — CHILDRENS CRISIS INTERVENTION PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS CRISIS INTERVENTION PROGRAM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356798383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 OYSTER POINT BLVD
Provider Second Line Business Mailing Address:
SUITE 501
Provider Business Mailing Address City Name:
SOUTH SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94080-1904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-866-4080
Provider Business Mailing Address Fax Number:
650-866-4081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 FLORIDA AVE STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95350-4430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-661-8840
Provider Business Practice Location Address Fax Number:
209-661-4843
Provider Enumeration Date:
05/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
VERNON
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
650-866-4080

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  415200481 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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