Basic Information
| Provider Information | |||||||||
| NPI: | 1942408794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157461940 | ||||||||
| FaxNumber: | 4157461941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1735 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157461940 | ||||||||
| FaxNumber: | 4157461941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 04/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | CAIN | ||||||||
| AuthorizedOfficialFirstName: | JOEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISRTATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4157461967 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HAIGHT ASHBURY FREE CLINICS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 550000486 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR0400X | 380016ACN | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 380016ACN | 01 | CA | DADP CERTIFICATION | OTHER | 550000486 | 01 | CA | LICENSE | OTHER | CMM71176F | 05 | CA | MEDICAID |