Basic Information
| Provider Information | |||||||||
| NPI: | 1053526715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONITA HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6333 TELEGRAPH AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109231099 | ||||||||
| FaxNumber: | 5109230894 | ||||||||
| Practice Location | |||||||||
| Address1: | 1422 HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946123903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108091780 | ||||||||
| FaxNumber: | 5108931642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 03/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | CRISPINO | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5109231099 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 01EE1 | CA | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 01EE1 | 05 | CA | MEDICAID |