1003208281 NPI number — BAY HORIZON ICF-DDH

Table of content: (NPI 1003208281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003208281 NPI number — BAY HORIZON ICF-DDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY HORIZON ICF-DDH
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:
1003208281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1565 ROYAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94401-3432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-347-1164
Provider Business Mailing Address Fax Number:
650-348-2795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 OCEAN VIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94401-3029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-347-1164
Provider Business Practice Location Address Fax Number:
650-348-2795
Provider Enumeration Date:
02/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GANIO
Authorized Official First Name:
PUREZA
Authorized Official Middle Name:
AGUZAR
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
650-520-5545

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  220000319 , 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)

  • Identifier: LTC60671G . This is a "PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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