Basic Information
| Provider Information | |||||||||
| NPI: | 1225327786 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST VINCENTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 IRIS RD | ||||||||
| Address2: | |||||||||
| City: | HERCULES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945471215 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 SAINT VINCENTS DR | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949031504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155072000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 04/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | FAMILY SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4155072000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.