Basic Information
| Provider Information | |||||||||
| NPI: | 1063509123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORDILLERAS MENTAL HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORDILLERAS MENTAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | 5103377969 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 EDMONDS RD | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940623813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503671890 | ||||||||
| FaxNumber: | 6503696465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | LANGFELD | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO/ SVP | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | DMH 02 68 015 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | ZZR18511G | 01 | CA | MEDICAID | OTHER |