1285837583 NPI number — SECOND CHANCE CABRILLO CENTER

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 1285837583 NPI number — SECOND CHANCE CABRILLO CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SECOND CHANCE CABRILLO CENTER
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:
1285837583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-792-4357
Provider Business Mailing Address Fax Number:
510-745-1692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4673 THORNTON AVENUE
Provider Second Line Business Practice Location Address:
SUITE P
Provider Business Practice Location Address City Name:
FREEMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-745-1675
Provider Business Practice Location Address Fax Number:
510-744-0674
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCONVILLE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
510-792-4357

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0193 , 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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