Basic Information
Provider Information | |||||||||
NPI: | 1073695011 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TELECARE CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VILLA FAIRMONT MENTAL HEALTH REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1080 MARINA VILLAGE PKWY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | ALAMEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 945016427 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103377950 | ||||||||
FaxNumber: | 5103377969 | ||||||||
Practice Location | |||||||||
Address1: | 15200 FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | SAN LEANDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 94578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103529690 | ||||||||
FaxNumber: | 5103529008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 06/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIS | ||||||||
AuthorizedOfficialFirstName: | LESLIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SVP, CFO | ||||||||
AuthorizedOfficialTelephone: | 5103377950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | DMH 02 099 104 | CA | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
No ID Information.