Basic Information
Provider Information | |||||||||
NPI: | 1558807230 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE ALLIANCE FOR COMMUNITY WELLNESS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LA FAMILIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26081 MOCINE AVE | ||||||||
Address2: |   | ||||||||
City: | HAYWARD | ||||||||
State: | CA | ||||||||
PostalCode: | 945442923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108815921 | ||||||||
FaxNumber: | 5108815925 | ||||||||
Practice Location | |||||||||
Address1: | 4521 WEBSTER ST | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946092140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108815921 | ||||||||
FaxNumber: | 5108815925 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2017 | ||||||||
LastUpdateDate: | 06/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SALVATIER | ||||||||
AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
AuthorizedOfficialTitleorPosition: | OPERATION & ADMINISTRATOR MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5103003500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 0105 | 05 | CA |   | MEDICAID |