Basic Information
| Provider Information | |||||||||
| NPI: | 1104036383 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAY AREA COMMUNITY SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SOUTH COUNTY WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 40TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946092633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106130320 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40963 GRIMMER BLVD | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106577425 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | STANTON | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 5105459763 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01GS1 | 05 | CA | MEDICAID |