Basic Information
| Provider Information | |||||||||
| NPI: | 1386834190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF CALIFORNIA, SAN FRANCISCO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DSAAM OPIATE TREATMENT OUT-PATIENT PROGRAM DETOX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7464 | ||||||||
| Address2: | DSAAM METHADONE DETOX | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941207464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155027648 | ||||||||
| FaxNumber: | 4155028175 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 POTRERO AVE | ||||||||
| Address2: | SFGHMC, BLDG.90, WARD 95 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152068412 | ||||||||
| FaxNumber: | 4152066875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CPG BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4152068969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.