Basic Information
| Provider Information | |||||||||
| NPI: | 1861090086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 GLEN CANYON CIR | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945656458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107591320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2334 BUCHANAN RD STE 2356 | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945094411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9254368766 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2020 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | JONTA | ||||||||
| AuthorizedOfficialMiddleName: | LARON | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5107591320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LAADAC | ||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.