Basic Information
| Provider Information | |||||||||
| NPI: | 1538204011 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOSS BEACH HOMES, INC. - SNBC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUNSET NEIGHBORHOOD BEACON CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 OYSTER POINT BLVD | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940801904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508664080 | ||||||||
| FaxNumber: | 6508664082 | ||||||||
| Practice Location | |||||||||
| Address1: | 3925 NORIEGA ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941223935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157593690 | ||||||||
| FaxNumber: | 4157590883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | VERNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6508664080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOSS BEACH HOMES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.