Basic Information
Provider Information | |||||||||
NPI: | 1528136389 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MISSION AREA HEALTH ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MISSION NEIGHBORHOOD HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 240 SHOTWELL ST | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941101390 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4155523870 | ||||||||
FaxNumber: | 4154313178 | ||||||||
Practice Location | |||||||||
Address1: | 4434 MISSION ST | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941121927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4154061353 | ||||||||
FaxNumber: | 4154313178 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2006 | ||||||||
LastUpdateDate: | 03/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STOREY | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: | Y | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/ EXECUTIVE DIR. | ||||||||
AuthorizedOfficialTelephone: | 4155523870 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 220000348 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.