Basic Information
| Provider Information | |||||||||
| NPI: | 1619155942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN MATEO COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EDMONDS RD | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940623803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 EDMONDS RD | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940623803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6508391810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP HOME COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7076940353 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CANYON OAKS YOUTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.