Basic Information
| Provider Information | |||||||||
| NPI: | 1225544638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INSTITUTO FAMILIAR DE LA RAZA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2919 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152290500 | ||||||||
| FaxNumber: | 4156473662 | ||||||||
| Practice Location | |||||||||
| Address1: | 5128 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152290500 | ||||||||
| FaxNumber: | 4156473662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | VILLACREZ | ||||||||
| AuthorizedOfficialFirstName: | CLERY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4152290500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INSTITUTO FAMILIAR DE LA RAZA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | IFR2919IN | 01 | SAM -SYSTEM OF AWARD MANAGEMENT REGISTRATION | OTHER |