Basic Information
| Provider Information | |||||||||
| NPI: | 1023337243 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY'S CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 925 BROCKHURST ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946084222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109239600 | ||||||||
| FaxNumber: | 5109239606 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 BROCKHURST ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946084222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109239600 | ||||||||
| FaxNumber: | 5109239606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5109239600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | ASW 27607 | CA | Y | Agencies | Case Management |
No ID Information.