1629468905 NPI number — CASA SERENA EATING DISORDERS PROGRAM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629468905 NPI number — CASA SERENA EATING DISORDERS PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASA SERENA EATING DISORDERS 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:
6
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:
1629468905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1868 CLAYTON RD
Provider Second Line Business Mailing Address:
SUITE 123
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94520-2547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-682-8252
Provider Business Mailing Address Fax Number:
925-682-8313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1868 CLAYTON RD
Provider Second Line Business Practice Location Address:
SUITE 123
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94520-2547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-682-8252
Provider Business Practice Location Address Fax Number:
925-682-8313
Provider Enumeration Date:
01/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HOLMES
Authorized Official First Name:
JACQUELYN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
925-682-8252

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC25575 , 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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