Basic Information
| Provider Information | |||||||||
| NPI: | 1467966259 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONTRA COSTA COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROOKSIDE SHELTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 50 DOUGLAS DR | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945534098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259575429 | ||||||||
| FaxNumber: | 9259575401 | ||||||||
| Practice Location | |||||||||
| Address1: | 847 BROOKSIDE DR STE C | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948011314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259575429 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 12/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DECESARE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | FISCAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9259575429 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONTRA COSTA COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 177F00000X | Y | Other Service Providers | Lodging |
No ID Information.