Basic Information
| Provider Information | |||||||||
| NPI: | 1013231646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY/HEALTH CARE FOR HOMELESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 FRUITVALE AVE STE 3E | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105321930 | ||||||||
| FaxNumber: | 5105320963 | ||||||||
| Practice Location | |||||||||
| Address1: | 2272 SAN PABLO AVE | ||||||||
| Address2: | HCHP ST.VINCENT'S STABLE SITE CLINIC | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946121321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105321930 | ||||||||
| FaxNumber: | 5105321930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | MODERSBACH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5105321930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | N | Agencies | Public Health or Welfare | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1881632867 | 01 | ORIGINAL NPI | OTHER |