Basic Information
| Provider Information | |||||||||
| NPI: | 1093095150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STARVISTA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARCHWAY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 ELM ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940703070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505919623 | ||||||||
| FaxNumber: | 6505914163 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 PRICE AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505919623 | ||||||||
| FaxNumber: | 6505914163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2011 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOHERTY | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | HUMAN RESOUCES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6505919623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.