Basic Information
Provider Information | |||||||||
NPI: | 1134423767 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASPIRANET | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASPIRANET - WRAPAROUND | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 OYSTER POINT BLVD SUITE 501 | ||||||||
Address2: |   | ||||||||
City: | SOUTH SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 940801904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6508664080 | ||||||||
FaxNumber: | 6508664082 | ||||||||
Practice Location | |||||||||
Address1: | 1620 CUMMINS DR | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953586400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095761750 | ||||||||
FaxNumber: | 2095761768 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2010 | ||||||||
LastUpdateDate: | 07/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | VERNON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6508664080 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ASPIRANET | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 415200481 | CA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 50BR | 05 | CA |   | MEDICAID |