1982876702 NPI number — CASA NOVA ICF/DD-H

Table of content: (NPI 1982876702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982876702 NPI number — CASA NOVA ICF/DD-H

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASA NOVA ICF/DD-H
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:
1982876702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3937 CASANOVA DR
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:
94403-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-341-9620
Provider Business Mailing Address Fax Number:
650-525-1167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3937 CASANOVA DR
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:
94403-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-341-9620
Provider Business Practice Location Address Fax Number:
650-525-1167
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ
Authorized Official First Name:
YOLANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSEE/CFO
Authorized Official Telephone Number:
650-303-0788

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , 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: LTC 60829F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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