1629468905 NPI number — CASA SERENA EATING DISORDERS PROGRAM

Table of content: (NPI 1629468905)

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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