Basic Information
Provider Information | |||||||||
NPI: | 1033326095 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UJIMA FAMILY RECOVERY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UJIMA HOPE SOLANO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1901 CHURCH LN | ||||||||
Address2: |   | ||||||||
City: | SAN PABLO | ||||||||
State: | CA | ||||||||
PostalCode: | 948063707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5102363139 | ||||||||
FaxNumber: | 5102363200 | ||||||||
Practice Location | |||||||||
Address1: | 251 GEORGIA STREET | ||||||||
Address2: |   | ||||||||
City: | VALLEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 94590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075588500 | ||||||||
FaxNumber: | 7075588508 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2007 | ||||||||
LastUpdateDate: | 04/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHANK | ||||||||
AuthorizedOfficialFirstName: | RITA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5102363139 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UJIMA FAMILY RECOVERY SERVICES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 15-00005117 | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.