Basic Information
| Provider Information | |||||||||
| NPI: | 1164837837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASQUEZ | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ALLERTON ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505999955 | ||||||||
| FaxNumber: | 6505999273 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 ALLERTON ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505999955 | ||||||||
| FaxNumber: | 6505999273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2014 | ||||||||
| LastUpdateDate: | 06/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 99475591C54141 | 05 | CA | MEDICAID |