Basic Information
| Provider Information | |||||||||
| NPI: | 1962554873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTA BATES SUMMIT MEDICAL CENTER ADULT DAY CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742920 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900742920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553981633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102044444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | GATES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO SHBA | ||||||||
| AuthorizedOfficialTelephone: | 5104507357 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | ADU70083G | 05 | CA | MEDICAID |