Basic Information
Provider Information
NPI: 1558424374
EntityType: 2
ReplacementNPI:  
OrganizationName: WESTCOAST CHILDREN'S CLINIC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3301 E 12TH ST STE 259
Address2:  
City: OAKLAND
State: CA
PostalCode: 946012940
CountryCode: US
TelephoneNumber: 5102699030
FaxNumber: 5102699031
Practice Location
Address1: 3301 E 12TH ST STE 259
Address2:  
City: OAKLAND
State: CA
PostalCode: 946012940
CountryCode: US
TelephoneNumber: 5102699030
FaxNumber: 5102699031
Other Information
ProviderEnumerationDate: 12/19/2006
LastUpdateDate: 08/07/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FERNANDO
AuthorizedOfficialFirstName: APRIL
AuthorizedOfficialMiddleName: DESIREE
AuthorizedOfficialTitleorPosition: CLINICAL DIRECTOR
AuthorizedOfficialTelephone: 5102699098
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PHD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251S00000X CAY AgenciesCommunity/Behavioral Health 

ID Information
IDTypeStateIssuerDescription
8193101CAMEDI-CAL PROVIDER NUMBEROTHER


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