Basic Information
| Provider Information | |||||||||
| NPI: | 1487872974 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN MATEO MEDICAL CENTER METHADONE TREATMENT PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 W 39TH AVE | ||||||||
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| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944034364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505732222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 795 WILLOW RD | ||||||||
| Address2: | BUILDING 332 | ||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940252539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505787190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEAN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6505787190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 4104 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | HDC70098F | 05 | CA | MEDICAID |